Preferred Auto-Ship Member Signup Form

If you were referred by a website, search engine or friend, please enter the name here:

Billing information. Please enter the address information in which you receive your credit card statement.

Bill to Name: Mr. Mrs. Ms. Miss.

Bill to Address:

Bill to Address2

City State Zip Code

Day Phone Number 

Evening Phone Number 

Email Address

Shipping Address. Complete only if different from your billing information.
Please Note: We ship via UPS to the 48 US Mainland States and Canada. UPS does not deliver to post office boxes. ** PO Box orders, please see below.

Ship to Name: 

Ship to Address:

Ship to Address2:

City State Zip Code

Please ship me the following product selection;
Please make your selection 1 Bottle - Coral Calcium 1 - $15.95 + $7.95 s&h = $23.90 ** 2 Bottles - Coral Calcium 1 - $31.90 + $7.95 s&h =39.85** 3 Bottles - Coral Calcium 1 - $47.85 + $7.95 s&h = $55.80 **

** PO Boxes within the 48 cont. states shipped via USPS - Priority Mail. 
An additional $1.00 will be added
** Alaska, Hawaii, Puerto Rico, Guam and APO shipments are shipped via USPS - Priority Mail. An additional $2.00 will be added to shipments to AK, HI, PR, Guam & APO addresses. 

*** We are no longer shipping to Canada.

Please charge my credit card and ship my first Auto-ship order:
  Please choose your ship date TODAY and then each month on the day selected below. Begin Auto-Ship on date selected below

Then I wish to have my next order billed and shipped on:
Choose  Day 1st 8th 15th 22nd -- Select Month This Month Next Month
and on the same day of each month following..

Your order should be delivered within 7 business days after the day you authorized. (Holidays and Weekends may slightly delay delivery).

Payment Information:

Type of Card: Visa MasterCard Novus/Discover American Express
Credit Card Number:
CV or CID Code: what is this?
Card Holders name on card:

Expires: Month  00 01 02 03 04 05 06 07 08 09 10 11 12 Year 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

I  wish to become a Preferred Customer of BuyCoralCalcium.com and upon submission of this form I hereby authorize BuyCoralCalcium.com to debit my credit card and ship my order selection on the selected date of each month following.

I further affirm that the name and personal information provided on this form are true and correct.

I understand that I can cancel this auto-ship order at anytime by notifying BuyCoralCalcium.com at least 10 days before my next scheduled shipment date.

I hereby affix my electronic signature and by pressing the ORDER button below,  agree to pay BuyCoraLCalcium.com.