YourMenopauseType®com, Inc.
325 31st St NW Cedar Rapids 52405
Tel: 319-390-4535 Fax: 319-538-0088
Order Form

 

Name of Program

Cost

Management of Menopause Type® Program

$195.00

 

 

Total

 

 

Please enclose check or money order or credit card information.

 

Name:

 

 

 

 

 

Business:

 

 

 

 

 

Address:

 

 

 

 

 

City:

 

 

 

 

 

State:

 

 

 

 

 

Zip Code:

 

 

 

 

 

Country:

 

 

 

 

 

Telephone:

 

 

 

 

 

E-Mail:

 

 

 

 

 

Password:

 

 

 

Please choose a password of 4 or more letters or numbers. This password will be used for entry into the Management of Menopause Type® Program. We will send you an E-Mail telling you when your password has been activated.

 

 

Credit Card #:

 

 

Expiration Date:

 

 

Signature:

 

 

 

Fax to 319-538-0088

 

Thank You

 

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