BiJuliet Consultation Fax Form, to meet immediately call 661-201-6462

Print, Complete and FAX to 661-451-5000 only needed for credit card payments, call above# to confirm time!

Name On Card:____________________________________________________________________________

Billing Address____________________________________________________________________________

City_______________________________________State__________________________Zip______________

Phone: ___________________________________EMAIL Address:__________________________________

Credit Card #____________/___________/___________/__________Exp. Date _______________________

Visa Card,  Master Card, Discover  (Please Circle One)  cvc# _____ (last 3 digits on back in signature area)

Signature:_____________________________________________Today's Date:________________________

Please Circle Your options
*** You WILL NOT be mailed ANYTHING unless you request it! If you chose to accept Free Offer below we can discuss your choice on the phone when we talk! 
It will be mailed DISCRETELY ONLY if you choose to accept FREE Offer  CD

I GIVE THE RIGHT TO "Earthstar" THE RIGHT TO CHARGE MY CREDIT CARD
 $_______________________(Total Amount For Phone Time Chosen Above)

PRINT NAME HERE : _________________________________________ DATE: ____________________________

SIGN HERE : _________________________________________
I am over 21 Years of Age

CD MAILING ADDRESS if different from above, will be confirmed on phone consultation!

Name On Card:____________________________________________________________________________

Billing Address____________________________________________________________________________

City_______________________________________State__________________________Zip______________