Fax/Mail Order Form
Safra Weightloss System
To order by fax or mail, please print out this form and fill in clear handwriting (preferably capital letters). Alternatively you may simply copy this form to your word-processor using copy/paste and fill it there. Then send to:
Yechiel Safra
P.O. Box 70
Hertzeliya 46100
ISRAEL
Or fax to: <Your international access code> +972 9 9545128
1. Mailing Address:
Name: _____________________________________
Street: _____________________________________
City/State _______________________
Zip Code: _______________________
Country _______________________
 
2. Credit Card Details: (please check Visa or MC. We currently do not accept AMEX or Diners Club)
Visa ___
Mastercard ___
Credit Card Number _________________________________
CVC Code (3 last digits on back of the card) ___________
Expiry Date (mm/yy) ____/____
Price $98
 
3. Card Holder's details as shown in credit company's records:
___As Above (if you check "as above" you do not have to fill this section):
 
Name: _____________________________________
Street: _____________________________________
City/State _______________________
Zip Code: _______________________
Country _______________________
 
4. Contact details
Phone Number ____________________________
Fax number ____________________________
Email ____________________________
 
5. In what language would you prefer to receive Safra Weightloss System?
English / Hebrew
Thank you!