| Last
Name: |
* |
Mucinex®-D
Tablets
|
...or generic equivalent to
Mucinex®-D
Tablets
|
| First Name: |
*
|
| Middle Initial: |
|
| Name as it appears on
credit card: |
*
NO
GIFT CARDS OR PREPAID CARDS ALLOWED!
|
| Daytime Phone: |
*
|
| Evening Phone: |
* |
|
Email Adress:
|
* |
Due to new Federal
Regulations on pseudoephedrine there is a limit of two (2) packages per
household per transaction. Also, you may not purchase more than five
(5) packages per 30 day period.
We will only ship to the
address that is the same as the billing address where your credit card
statements are sent and that matches your photo ID. |
|
Home Address:
|
*
Provide
address that your credit card
statements
are sent
to and that appears on your ID.
|
| City: |
*
|
| State: |
*
If your
U.S. state is not listed, we cannot ship there.
|
| Zip Code: |
*
|
NOTICE: Under 18 USC
§ 1001, anyone who makes a materially false, fictitious, or fraudulent
statement to the US Government is subject to criminal penalties.
Penalties may include a fine of up to $250,000 and/or imprisonment for up
to 5 years. |
| Country: |
|
|
|
|
|
| Select your card: |
|
 |
| Card number: |
*
|  |
| Card expiration: |
/
* |
| CV V 2 |
*
(Security Code) |
| QUANTITY: |
|
|
| Special Instructions
or comments: |
|
Please note what item(s) you are
requesting and quantity of each item |
|
AUTOSHIP?
|
, EVERY DAYS |
With AutoShip,
we'll
automatically bill your card on file and ship your order to
you until either your credit card or photo ID expires or you cancel.
To cancel or change frequency of shipments please send email to Services@RxPalace.com |
