info@illumavein.com
612.600.6538
Credit Card Payment
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TOTAL:  $34.99 per unit (Tax in Minnesota for a total of $37.54)
Enjoy free shipping for the month of October 2012 (within the United States)
*You will receive a receipt by email (please allow 24 hours for processing)*
Name as it appears on the credit card:
Quantity you would like to order:
Credit Card Number:
Expiration date (mm/yy)
CVV (3 digit number on the back of Mastercard and Visa,
and the 4 digit number on the front of American Express)
Billing Address:
Billing Address 2 (suite, apt #):
Billing City:
Billing State:
Billing Zip Code:
Enter shipping address if different from above:
Shipping Address:
Shpping Address 2 (suite, apt #):
Shipping City:
Shipping State:
Shipping Zip Code:
Your phone number:
Your Email address: