LEIS OF HAWAII

POLYNESIAN BROWN OIL

Date Ordered: Date of Delivery:

PLEASE CHECK ONE - SHIPPING TO BUSINESS - SHIPPING TO RESIDENCE

                                                                

Company Ship To:

c/o Name:

Address:

City: State: Zip Code:

Phone: Area Code - Ext: 1-800 or 888: -

Fax: Area Code - E-mail:

Contact Name:

How did you hear of our company?

Per 8 oz. Bottles

*POLYNESIAN BROWN OIL*

Individual

- - - - - - - - - - - - - - - Type Of Item - - - - - - - - Bottle Count & Price - - - - - - - - - - - - - - - - Total

*Individual - 8 oz. Bottle - Natural*

PLEASE CHECK ONE - Spray Top ---------- or ---------- Flip Top

                                                                

Qty () X = $

*Individual - 8 oz. Bottle - w/SPF 4*

PLEASE CHECK ONE - Spray Top ---------- or ---------- Flip Top

                                                                

Qty () X = $

*Individual - 8 oz. Bottle - w/SPF 15*

PLEASE CHECK ONE - Spray Top ---------- or ---------- Flip Top

                                                                

Qty () X = $

*Individual - 8 oz. Bottle - w/SPF 30*

PLEASE CHECK ONE - Spray Top ---------- or ---------- Flip Top

                                                                

Qty () X = $

Per 16, 4, 2, 1 oz. Bottles

*Bottles listed below are special orders only.*

- - - - - - - - - - - - - - - Type Of Item - - - - - - - - Bottle Count & Price - - - - - - - - - - - - - - - - Total

*Individual - 16 oz. Bottle - Natural*

PLEASE CHECK ONE - Spray Top ---------- or ---------- Flip Top

                                                                

Qty () X = $

*Individual - 16 oz. Bottle - w/SPF 4*

PLEASE CHECK ONE - Spray Top ---------- or ---------- Flip Top

                                                                

Qty () X = $

*Individual - 16 oz. Bottle - w/SPF 15*

PLEASE CHECK ONE - Spray Top ---------- or ---------- Flip Top

                                                                

Qty () X = $

*Individual - 16 oz. Bottle - w/SPF 30*

PLEASE CHECK ONE - Spray Top ---------- or ---------- Flip Top

                                                                

Qty () X = $

*Individual - 4 oz. Bottle - Natural*

PLEASE CHECK ONE - Spray Top ---------- or ---------- Flip Top

                                                                

Qty () X = $

*Individual - 4 oz. Bottle - w/SPF 4*

PLEASE CHECK ONE - Spray Top ---------- or ---------- Flip Top

                                                                

Qty () X = $

*Individual - 4 oz. Bottle - w/SPF 15*

PLEASE CHECK ONE - Spray Top ---------- or ---------- Flip Top

                                                                

Qty () X = $

*Individual - 4 oz. Bottle - w/SPF 30*

PLEASE CHECK ONE - Spray Top ---------- or ---------- Flip Top

                                                                

Qty () X = $

*Individual - 2 oz. Bottle - Natural*

PLEASE CHECK ONE - Spray Top ---------- or ---------- Flip Top

                                                                

Qty () X = $

*Individual - 2 oz. Bottle - w/SPF 4*

PLEASE CHECK ONE - Spray Top ---------- or ---------- Flip Top

                                                                

Qty () X = $

*Individual - 2 oz. Bottle - w/SPF 15*

PLEASE CHECK ONE - Spray Top ---------- or ---------- Flip Top

                                                                

Qty () X = $

*Individual - 2 oz. Bottle - w/SPF 30*

PLEASE CHECK ONE - Spray Top ---------- or ---------- Flip Top

                                                                

Qty () X = $

*Individual - 1 oz. Bottle - Natural*

PLEASE CHECK ONE - Spray Top ---------- or ---------- Flip Top

                                                                

Qty () X = $

*Individual - 1 oz. Bottle - w/SPF 4*

PLEASE CHECK ONE - Spray Top ---------- or ---------- Flip Top

                                                                

Qty () X = $

*Individual - 1 oz. Bottle - w/SPF 15*

PLEASE CHECK ONE - Spray Top ---------- or ---------- Flip Top

                                                                

Qty () X = $

*Individual - 1 oz. Bottle - w/SPF 30*

PLEASE CHECK ONE - Spray Top ---------- or ---------- Flip Top

                                                                

Qty () X = $

Per 8 oz. Bottles

*POLYNESIAN BROWN OIL*

PLEASE CHECK ONE - Spray Top ---------- or ---------- Flip Top

                                                                 

Volume

- - - - - - - - - - - - - - - Type Of Item - - - - - - - - Bottle Count & Price - - - - - - - - - - - - - - - - Total

*Volume - 8 oz. Bottle - Natural*

Qty () X = $

*Volume - 8 oz. Bottle - w/SPF 4*

Qty () X = $

*Volume - 8 oz. Bottle - w/SPF 15*

Qty () X = $

*Volume - 8 oz. Bottle - w/SPF 30*

Qty () X = $

Per 16, 4, 2, 1 oz. Bottles

*Bottles listed below are special orders only.*

- - - - - - - - - - - - - - - Type Of Item - - - - - - - - Bottle Count & Price - - - - - - - - - - - - - - - - Total

*Volume - 16 oz. Bottle - Natural*

Qty () X = $

*Volume - 16 oz. Bottle - w/SPF 4*

Qty () X = $

*Volume - 16 oz. Bottle - w/SPF 15*

Qty () X = $

*Volume - 16 oz. Bottle - w/SPF 30*

Qty () X = $

*Volume - 4 oz. Bottle - Natural*

Qty () X = $

*Volume - 4 oz. Bottle - w/SPF 4*

Qty () X = $

*Volume - 4 oz. Bottle - w/SPF 15*

Qty () X = $

*Volume - 4 oz. Bottle - w/SPF 30*

Qty () X = $

*Volume - 2 oz. Bottle - Natural*

Qty () X = $

*Volume - 2 oz. Bottle - w/SPF 4*

Qty () X = $

*Volume - 2 oz. Bottle - w/SPF 15*

Qty () X = $

*Volume - 2 oz. Bottle - w/SPF 30*

Qty () X = $

*Volume - 1 oz. Bottle - Natural*

Qty () X = $

*Volume - 1 oz. Bottle - w/SPF 4*

Qty () X = $

*Volume - 1 oz. Bottle - w/SPF 15*

Qty () X = $

*Volume - 1 oz. Bottle - w/SPF 30*

Qty () X = $

T-Shirts (S - XXL)

*T-Shirts - $20.00 each*

- - - - - - - - - - - - - - - Sizes Of Item - - - - - - - - - - Cost Per Item - - - - - - - - - - - - - - - - - - - - - Total

Qty () X                                                     = $

Tank Tops (S - XXL)

*Tank Tops - $15.00 each*

- - - - - - - - - - - - - - - Sizes Of Item - - - - - - - - - - Cost Per Item - - - - - - - - - - - - - - - - - - - - - Total

Qty () X                                           = $

Caps (One size fits all)

*Caps - $12.00 each*

- - - - - - - - - - - - - - - Sizes Of Item - - - - - - - - - - Cost Per Item - - - - - - - - - - - - - - - - - - - - - Total

Qty () X                                                           = $

BOX CHARGE: MAINLAND - NEIGHBOR ISLAND - INTERNATIONAL

Qty () - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - $

PACKING/HANDLING/AGRICULTURE USDA STAMP ($5.95 PER BOX)

Important notice - Placing last minute orders to be shipped the same day is subject to a surcharge fee of $17.00 Airbill.

SAME DAY SERVICE ORDER ($17.00)

Important notice - Federal Express Charges $12.50 more per box for Saturday Delivery. You may wish to receive your shipment on Friday for that weekend. Shipping to any State east of the Colorado Mountains is two days delivery from Hawaii.

If you wish to use your own Personal or Business

Federal Express Account Number - Enter It Below

#

*Freight Not Included - Federal Express*

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - SUBTOTAL $

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -HI Tax 4.17% $

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - TOTAL DUE $

Payment: Visa or Master Card accepted through LEIS OF HAWAII

Credit Cards Type:

Card No:

This Credit Card Will Not Be Valid Unless You Submit Your

Last 3 Digit Numbers Located On The Back Of Your Credit Card:

#

Exp. Date: 00/00

Name Of Person As It Appears On The Card:

Credit Card Billing Address:

City: State: Zip Code:

Phone: Area Code - Ext: 1-800 or 888: -

Fax: Area Code - E-mail:

When complete, click "submit" to email Leis Of Hawaii. If you wish to have a hard copy of your order, please print "Form Confirmation" page after submitting. Please allow processing time. You will be contacted by your email below once your Credit Card has been approved, which will confirm your order. You will be contacted by your email if there is any problem with your order.

E-mail:

Comments:

 

Polynesian Brown Oil

A subsidiary of Network of Workers, Corporate Office - Las Vegas

Toll-Free Reservations: 1-888-534-7644 (1-888-LEIS-OF-HI)

P.O. Box 90994 Honolulu, Hawaii 96835

(808) 735-0824 or Fax (808) 735-0165

&

LEIS OF HAWAII

The Perfect Start To Your Hawaiian Holiday

(808) 732-7385 or Fax (808) 732-7134

E-mail: leisofhawaii@msn.com

Visa or Master Card accepted through LEIS OF HAWAII

Web page publishing and graphic design by: LEIS OF HAWAII

E-mail: polynesianbrownoil@msn.com

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