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CUSTOMER INFORMATION:
NOTE: All fields marked with an * are REQUIRED! First Name * Last Name * e-mail address * Address Line 1 * Address Line 2 (optional) City * State * (TIP: Type the first letter of your state to jump down the list!) Zip Code * or Mail Code* USA or Other Country Contact Telephone Number* PAYMENT INFORMATION: CCV/CID Number:
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| If you are paying with a credit card
but you prefer calling this information in rather than submitting it online
via this SECURE ENCRYPTED form, then complete the rest of your order and check
below: I AM CALLING IN WITH MY PAYMENT INFORMATION! Call 866-897-7296 between 9 AM and 7 PM Pacific Time to leave your credit card account information. If you reach our recording, then we are on the phone with another customer. Please leave your name and phone number and we will call you back when we are done with the other customer or during our business hours. Comments/Suggestions: YOU MUST CLICK ON THE "Send Order" BUTTON TO COMPLETE YOUR PURCHASE! Please click only once! © 1999-2012 Emerald City Reiki Center. All Rights Reserved. PO Box 6955, Portland, OR 97214 866-897-7296 email us
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