Bravo Smokes - the Easy way to stop smoking!

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Bravo Smokes Corporation Fax Order Form

Required Fields are labeled in red

Please fill out all the information below. Be sure to fill out your credit card number accurately, and make sure that you write your name as it appears on your credit card. Also, the address you fill in must match the billing address on your credit card statement.

Print this page, fill it out, and Fax to : 1-201-944-5252

Please send me :
Heavy Smoker's Survival Kits @ $87.50 per kit (shipping included)
Light Smoker's Survival Kits @ $55.50 per kit (shipping included)

Name	______________________________________
Phone Number	______________________________________
Email Address	______________________________________
Check this box to indicate that you are at least 18 years old, and are not considered a minor in your state

Bill To Information :
Address	_____________________
Address	_____________________
City	_____________________
State	_______
Postal Code	______________
Country	______________

Ship To (if different from Bill To) :
Name	_____________________
Address	_____________________
Address	_____________________
City	______________________
State	_______
Postal Code	______________
Country	______________

Payment Information

Card Type *

______________

Name on Credit Card *

______________________________________

Credit Card Number *

______________________________________

Expiration Date (enter MM/YY) *

______________

Return Policy : You may send back any unopened, undamaged packs of smokes that are suitable for resale. Bravo Smokes will refund $3.50 per pack up to and including one-half the orginal order's number of included packs. The shipping charge is not included in the refund.

Please be sure that your return shipment is well packaged so that the carton isn't damaged during its return to us.

Please allow 10 business days for delivery. Order a sufficient quantity of Bravo® Smokes to replace two weeks of your regular cigarette usage. Your order will ship via UPS, or US Postal Service Priority Mail.