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QTY DESCRIPTION 0 1 (total of $35.00) 2 (total of $70.00) 3 (total of $105.00) 4 (total of $140.00) 5 (total of $175.00) Oral Health Care Kit and FREE Samples @ $35.00 each 0 1 (total of $10.95) 2 (total of $21.90) 3 (total of $32.85) 4 (total of $43.80) 5 (total of $54.75) Free Nicotine Floss - $10.95 s/h BILLING INFORMATION Credit card VISA MasterCard Discover Cardholder name Card number Exp. date (mm/yy) Street address Address (cont.) City State/Province Zip/Postal code Country SHIPPING Street address Address (cont.) City State/Province Zip/Postal code Country
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