First Name:
Last Name:
Company Name (if applicable):
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Email Address:
Confirm Email Address:
Phone Number:
(We will only use this number to confirm or ask questions about your order. We will never sell it to any third party.)
Shipping Address:
We will use UPS to ship your order, so please use a street address for shipping.
Please check here if you would like to come in to Basics to pick up your order, and you can skip this section:
Address Line 1:
Address Line 2:
Address Line 3:
City:
State:
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DE
DC
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HI
ID
IL
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KS
KY
LA
ME
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MT
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NE
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NY
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OK
OR
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Zip Code:
Billing Address:
Please check here if it is the same as your mailing address
Address Line 1:
Address Line 2:
Address Line 3:
City:
State:
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MA
MI
MN
MS
MO
MT
ME
NE
NV
NH
NJ
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip Code:
A note regarding shipping charges:
We charge standard UPS shipping charges, which are based on the weight of the package and the zone to which we are sending the product, plus a $3.00 handling fee.
Payment Information:
All orders are handled over a secure socket layer (SSL), so your personal information is secure. If you would rather give us your credit card information over the phone, please give us a call at 608/754-3925.
Credit Card Number:
Expiration Date: :
Product Order:
Please provide as much detail as possible about the products you would like to order, including the company name, the size, and a full description of the product you would like.
If you would like to pay your Basics Cooperative ownership fee online, put "Basics Cooperative Ownership Fee" in the product description box.
If we have any questions, we will send you an e-mail or give you a call at the number you provided above. If you aren’t sure exactly what you would like to order, send us an e-mail at
info@Basicshealth.com
or give us a call at 608/754-3925. Please remember to submit your order when you are done by clicking the button below.
Quantity
Complete Description of Product
Comments:
Thanks for being a valued Basics customer!