Printable Order Form

Gold Stake Retail Order Form

4540 Post St., Suite 250 PMB #176	Phone: (800) 523-4653
El Dorado Hills, CA 95762	Fax 916-941-2304

Quantity	Product No.	Description	Retail Price	Total
	GS60	Gold Stake Mineral Supplement 60 Ct Bottle	26.25
	GS60C	Gold Stake Mineral Supplement 12 Bottles per case - 60 Ct Bottle	315.95
	GS125	Gold Stake Mineral Supplement 125 Ct Bottle	41.95
	GS125C	Gold Stake Mineral Supplement 12 Bottles per Case - 125 Ct Bottle	502.95
	GSP1	Gold Stake Mineral Bulk Powder 1 oz. Bottle	40.95
	GSP1C	Gold Stake Mineral Bulk Powder 12 Bottles per Case - 1oz. Bottle	490.95
	P7120	Product 7 Herbal Formula 100 Ct Bottle	24.95
	P7120C	Product 7 Herbal Formula 12 Bottles per Case - 100 Ct Bottle	301.75
	SALVE	Gold Stake Mineral Salve 2 oz. Jar	41.95
	WGEL4	Willared Ge'loe 4 oz. Tube	18.95
	WW1G	Willard Water 1 Gallon Bottle	157.49
	WW8	Willard Water 8 oz. Bottle	28.29
	WW4	Willard Water 4 oz. Bottle	19.95

Credit Card Name:________________________________

Credit Card Number:______________________________

Expiration Date: _________________________________

SUB -TOTAL

SHIPPING AND HANDLING

TOTAL AMOUNT DUE

Print Name of Purchaser on this Line:___________________________________________________________

Address:________________________________________	Phone:__________________________________
City:___________________________________________	State:___________________________________
Retail Sales Tax Number:____________________________ (not required outside California)	Zip Code:________________________________

1.5% interest per month charged on accounts past due over 30 days
For all Credit Card Sales, Call (800) 523-4653