|
FAX/MAIL ORDER FORM
|
 |
MAIL TO:
Global Sweet Polyols, LLC
Xylitol Works U.S.A. Division
125 Tremont St.
Rehoboth, MA 02769 USA
Phone (508) 252-5294
|
 |
|
FAX THIS FORM TOLL FREE TO 1-800-778-2357
|
Billing Address
Please fill out completely and PRINT clearly.
Name _____________________________________________________ |
| Address
___________________________________________________ |
| City ____________________
State/Province ___________________ Zip Code
_______________ |
| Country
____________________
Email (optional) ______________________________ |
| Phone Numbers
(home) _______________________ (work)
__________________________ |
Shipping Address Please fill out shipping address if different from above.
Name _____________________________________________________
|
| Address
___________________________________________________ |
| City ____________________
State/Province ___________________ Zip Code
_______________ |
| Country
____________________
Email (optional) ______________________________ |
| Phone Numbers
(home) _______________________ (work)
__________________________ |
Credit Card Information Please fill out completely or your order can not be
processed
|
Name
________________________________________________ (As it appears on
the credit card)
Credit Card #
____________________________________
CVV # (the last 3 numbers on the signature strip located on the BACK of
your credit card, for added security);
_________
Expiration Date
_________________
Signature
_____________________________________________
|
Method of Payment
 Visa
MasterCard
Discover
Check** |
|
**Please make checks payable to Global Sweet Polyols, LLC
|
| Please
visit www.GlobalSweet .com products
page for the following information |