If you would prefer to use a check or money order and bypass using the web ordering altogether

If you would prefer to use a cashiers check or money order and bypass using the web
ordering all together, You can simply send us this order form with a cashiers check
or money order for the total amount and we will gladly handle the order for you. You
can also Fax this form to us at 1 (270)721-0073. No personal checks please!

CASHIERS CHECK AND MONEY ORDER/FAX FORM GERMJUICE.COM C/O BLACK LIGHT WORLD

1.Fill out and print the following form. We do not ship to Outside the USA.
WE DO NOT ACCEPT PURCHASE ORDERS

First Name: Last Name:
Company name:

Ship to Address:
Street: City: State:

Zip Code:

Phone # Fax#

e-mail: Fill out to receive your Tracking Number.

Billing address (Leave Blank if same as above)
Street: City: State:

Zip Code: Credit Card (Circle One):

Credit card # (If Applicable) Expiration date
Security Code Reverse side. Include all digits American Express Security digits are on the front side of card

By entering this information you authorize Germjuice.com AKA Blacklightworld to charge your credit card. We accept Visa, Mastercard, American Express, and Discover.
Your credit card statement will read Black Light World

Selected item (s) :
Qty Item Name Item #

Special Instructions or comments:

Subtotal amount:

Shipping: Below rates are within the USA only!
The following rates apply to check, money orders, or faxed orders only for USA ONLY!
$0.01-$10.00 dollars $8.50
$10.01-$50.00: $8.95
$50.01-$100.00: $9.95
$100.01-$150.00: $12.95
$150.01-UP: $14.95
ABOVE RATES ARE NOT FOR DISTRIBUTORS OR DISCOUNTED PRICING. WEB PURCHASES ONLY.

Kentucky residents add 6.0% sales tax

Grand Total:

Signature:

2.Send form (be sure to include Cashiers Check or Money Order payable to BLACK LIGHT WORLD if applicable) to:
GERMJUICE.COM
C/O BLACK LIGHT WORLD
PO Box 26
Cub Run, Ky 42729

Or Fax to Germjuice.com C/O BLACK LIGHT WORLD

1(270)721-0073 Fax