AUSTIN NUTRITIONAL RESEARCH
Serving the Net since 1995

Secure EXPRESS Online Order Form

You have selected:
 ANR MAXIMUS Formula Monthly Auto Ship @ $49.95
Shipping and Handling Included in USA!

This is our EXPRESS USA Order Form, if you would like to place a different or more complex USA Order or International Order go to our regular SECURE ORDER FORM.  For more information on ordering, go to ORDER INFORMATION


Please provide the following ordering information:

       Full Name 
  Street Address 
 Address (cont.) 
            City 
  State/Province 
 Zip/Postal Code 
         Country   USA ONLY  
          E-mail 
      Work Phone 
      Home Phone 

Have you ordered from ANR before? 

YES          NO              Not Sure

If YES, do you currently have an Auto Ship already set up?

NO
YES, I would like this Auto Ship ADDED to my old one.
YES, I would like this Auto Ship to REPLACE my old one.

You can decide to have it charged to your credit card or automatically drafted from your checking account. Fill out either credit card OR checking account information.  Billing address of credit card or address on your check must match above ordering information.  Checking Account Drafts are accepted only for monthly automatic shipments in the USA and must be drawn on a USA bank. 

Please provide the following payment information. 

American Express, Mastercard, VISA, Discover

     Credit Card 
 Cardholder Name 
     Card Number 
 Expiration Date 

OR enter information using one of your checks below:

                Your Name  as it appears on check
             Your Address  as it appears on check
    Your City, State, Zip  as it appears on check
Transit Code upper number  or to left of /
Transit Code lower number  or to right of /
             Check Number 
                Bank Name 
             Bank Address  if on your check
        Bank Phone Number  if on your check
      Bank Routing Number 
      Your Account Number 
ALL numbers printed across bottom of check,
                         leaving spaces in place of symbols. 

Comments or special ordering instructions:
        
Example: "please send 2 Maximus Formulas monthly"



 

AUSTIN NUTRITIONAL RESEARCH
Nutritional Supplement Programs for People who KNOW Vitamins!
Mailing: PO BOX 203610; AUSTIN TX 78720-3610 USA
Shipping: 4815 W Braker Ln. Suite 502-180 Austin Texas 78759
FAX: (512) 267-4448
Voice: (512) 267-7644
email: <longlife@bga.com>
WorldWideWeb: http://www.anrvitamins.com
May yee be healthy and live long...;