Bill To: (Must match credit card address)

Ship To: (Leave blank if same as billing)

Name:

Name:

Address:

Address:

City:

City:

State:

State:

Zip:

Zip:

E-Mail:

Phone:

Qty.

Description

SKU

Price Each

Total

WhiteBrush Toothbrush

WBTB

$39.95

$

WhiteBrush Replacement Heads (2)

WBRH

$14.95

$

WhiteBrush Toothpaste

WBTP

$4.00

$

Sub Total

$

New York Residence Add 6% Sales Tax

$

Shipping & Handling Charge (See Below)

$

TOTAL

$

Visa □       M/C □       AmEx □      Discover □  

UPS charge based on sub total above.

Card Number:

$0.01 USD - $9.99 USD

$7.00

Exp. Date

$10.00 USD - $49.99 USD

$9.95

Verification Number:

$50.00 USD - $99.99 USD

$12.95

THANK YOU.

$100.00 USD - $199.00 USD

$16.95

$200.00 USD - And Up

$26.95