This form may be used to place orders by mail, E-mail or fax for domestic and international orders.

Name (as it appears on the credit card)

Company/Organization:

Resale permit (for wholesale inquiry only)

Billing Address:

City:

Province/State:

Postal Code:

Country:

Daytime Telephone Number: (		)
Facsimile Number: (		)

E-Mail Address:

Preferred method to contact you:

Merchandise Total

Californian Customers add 8.75% Sales Tax
(Not applicable for wholesale inquiry with a Valid resale permit)

FedEx Preferred method of shipping (Overnight, 2nd Day, 3-Day)

International FedEx Air

International Insurance

TOTAL in USD$

SHIPPING INFORMATION:
Domestic:

• Insurance charges within the United States are free.
• Indicate the method of shipping you will prefer to use and we will reply with the applicable shipping cost.

International:

• Please refer to our International shipping information page to obtain the appropriate shipping rate to your country. If your country is not listed, leave it blank and we will reply with the applicable shipping cost.
• Insurance charges are the responsibility of the customer. Please refer to our International shipping information page to obtain the appropriate insurance rate.
• Please note that orders for shipment outside the US are subject to higher shipping rates, and applicable customs, duties and taxes, all of which are the responsibility of the customer.

PAYMENT INFORMATION:

We accept American Express, Discover, Visa and Master Card.

Charge Card Number:

Card I.D. Number:

(This 4-digit number is found on the back or front of your credit card)

Expiration Date:

Signature:

SHIPPING INSTRUCTIONS:

Shipping Address:
(Please indicate shipping address if different from Billing address)

Special Instructions:

Thank you for your purchase. We will get back to you with your confirmation within the next business day.

FAX THIS FORM TO (510) 217-3785

OR

MAIL IT TO
MANNA TAHITI™
801 98th Avenue
Oakland, CA 94603

OR

E-MAIL IT TO