Order Form

To Order Any Products from Miami Aromatherapy,
please print this form, fill it in completely and follow the instructions at the end.

BODY	SIZE	QUANTITY	PRICE PER UNIT	SUB-TOTAL
SYNERGY
Burns	1 dram	x	$20.00	=
Munchies	1 dram	x	$20.00	=
Muscles	1 dram	x	$20.00	=
Nails	1 dram	x	$20.00	=
Public Speaking	1 dram	x	$20.00	=
Relaxation	1 dram	x	$20.00	=
Scarring	1 dram	x	$30.00	=
Temples	1 dram	x	$20.00	=
Wrists	1 dram	x	$20.00	=
Your Custom Blend			Please contact us
Sub - total:

SPIRIT	MODEL / SIZE	QUANTITY	PRICE PER UNIT	SUB-TOTAL
DIFFUSER
Manual / Auto	Beyond Diffusion	x	$118.50	=
11 min. on / 25 min. off	1125	x	$114.00	=
5 min. on / 25 off	525	x	$110.00	=
SYNERGIES
Florida Riviera™	4 ounces	x	$40.00	=
Penninsular Paradise™	4 ounces	x	$60.00	=
South Beach Synergy™	4 ounces	x	$30.00	=
Your Custom Blend			Please contact us
Sub - total:

BEAUTY	SIZE	QUANTITY	PRICE PER UNIT	SUB-TOTAL
SYNERGIES
After Sun Oils	1 dram	x	$30.00	=
A. M. Balancer™	1 dram	x	$30.00	=
Blemish Blend™	1 dram	x	$30.00	=
P. M. Soother™	1 dram	x	$45.00	=
Nine Day Synergy™	1 dram	x	$20.00	=
Sub - total:
Twelve	Synergies	Of	Essential	Oils™
January	1 dram	x	$30.00	=
February	1 dram	x	$30.00	=
March	1 dram	x	$30.00	=
April	1 dram	x	$30.00	=
May	1 dram	x	$30.00	=
June	1 dram	x	$30.00	=
July	1 dram	x	$30.00	=
August	1 dram	x	$30.00	=
September	1 dram	x	$30.00	=
October	1 dram	x	$30.00	=
November	1 dram	x	$30.00	=
December	1 dram	x	$30.00	=
Sub - total:

Products	From Sub - totals:
BEAUTY
BODY
SPIRIT
Sub - total:
Fla. Residents add 6.5% sales tax
for commercial accounts: Fla. sales tax number
Shipping & Handling
Grand Total

Please mail the completed order form
along with your check or money order payable to

Miami Aromatherapy, Inc.
P. O. Box 432510
Miami, Fl 33243 - 2510

If you would like to fax your order, please make sure to include your
checking account information below and we will process it
just as if your order were mailed or taken over the phone.

Please call us for faxing information at 305 - 662 - 2814
www. miamiaromatherapy .com

My checking account information is as follows and you are authorized to
deduct the total amount of my purchase from it:

Bank name: ________________________________________

Address:      ________________________________________

                    ________________________________________

Routing number: _____________________________________

Account number: ____________________________________

Check number: __________       Amount:    __________

Page 4 of 5
My name is:                  ________________________________
My address is:              ________________________________
                                    ________________________________

Day telephone number is: _____________________________

Dated: _______________________

Signature: _______________________________

Page 5 of 5

Name
Street Address
Apt. or Suite #
City, State, Zip Code
Telephone Number