2003 N. Tyler Ave.,
South El Monte CA 91733 USA
Tel: 800-518-3398, or 626-579-2668,
Fax: 626-582-8988
If you have any questions regarding this form, please call us at 626-579-2668, 9 am - 5 pm, Monday - Friday, Pacific Standard Time.
This form must be filled out for first time Vasopro customers. After this form has been faxed, or mailed to VitaSprings.com, and after it's on our file, you will not be required to file another Vasopro order form again unless regulations change.
Please fill out this form in its entirety. If any information is missing, your order cannot be processed.
Please fax this form to VitaSprings.com at 626-582-8988, or mail to: 2003 N. Tyler Ave., South El Monte CA 91733 USA.
You can also scan (with a copy of your drivers license attached) and email to info@vitasprings.com
ORDER NUMBER:____________________________________________
NAME:______________________________________________________
CURRENT ADDRESS:_________________________________________
CITY:____________________ STATE:__________ ZIP_____________
DATE OF BIRTH:______/______/________
PHONE: ______________________________
SIGNATURE:_______________________________ DATE:____/_____/_____
Signature is mandatory
(Please also glue or attach a photo copy of your current Driver License or State ID here.
If you worry about the security for faxing your ID, you may use a black marker to block your ID numbers.)
(Your address has to match the address placed on your order)
This personal information is for our internal use only. Your information WILL be kept absolutely confidential and handled responsibly. It will not be given, sold or lend to any third party organizations.