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Wholesale Membership Sign-up Form

Fax Orders
 You may fax your order to: 804-276-3504
Faxed orders please include credit card information.

PayPal or ProPay

Logon to your Paypal, or Propay account and send your money to:

sales@roscents.com

To Order by Mail
Mail to: Mr Darnell Ross, 1601 Bramwell Rd, Richmond, VA 23225
To pay by check or money order, please send $28.95 ($25.00 + 3.95s+h).

Name: _____________________________________________

Street Address: ___________________________________________________

City: ________________________________ State: _________ Zip: _________

Phone Number: (_____)__________-____________

Email: ____________________________________


 

 

payment information

Credit Card: Visa ___ Mastercard ___ American Express ___ Discover ___

Card Number: ____________-____________-____________-____________

Expiration Date: __________/____________

I've enclosed: (check one)

Check [ ]
Money Order [ ]

Please rush my wholesale membership supplies, including the entire catalog packet.

Signature: _______________________________________Date: _________________


Please tell us how you heard about us! (website name, search engine etc.) __________________________