Chakra Balance Flower Essences Order Form

DaKara Kies Company
P.O. Box 1354 Marysville, WA 98270

(425) 267-9738 OR 1-800-813-3877
FAX orders to (425) 953-4304

Print out, complete, and mail this form to the address above or
(Orders mailed to the PO Box may incur a delay of shipping of an additional week)

E-mail (Cut & Paste form): dakara@dakara.com

Order by phone at 1-800-813-3877
VISA & MASTERCARD ACCEPTED
Or FAX orders to (425) 953-4304

All funds USD

Ship to:

Name:_________________________________________________________________

Address :_______________________________________________________________

City:____________________________________ST________ ZIP_________________

E-Mail Address__________________________________________________________

Phone#(_______)________________________________________________________

VISA/MASTERCARD #___________________________________________________

Exp _____-_____ CVV # ________

Signature______________________________________________________

Billing Address if same as Shipping write SAME

Address:___________________________________________________

City:___________________________ ST __________ ZIP______________

(E-mail & FAX requests must include phone number)

All Funds USD

Item Description	Qty	Price	Total
Ground & Release 1 fl. oz Dosage	____	$12.95	$_____________
Divine Love 1 fl. oz. Dosage	____	$12.95	$_____________
Awaken to Spirit 1 fl. oz. Dosage	____	$12.95	$_____________
Ground and Release 1/2 fl. oz Stock Concentrate	____	$16.95	$_____________
Divine Love 1/2 fl. oz Stock Concentrate	____	$16.95	$_____________
Awaken to Spirit 1/2 fl. oz Stock Concentrate	____	$16.95	$_____________
Set of 3 - 1 ea. of Ground & Release, Divine Love & Awaken to Spirit
1 fl. oz set - Dosage	____	$33.00	$_____________
1/2 fl. oz. set - Stock Concentrate	____	$45.00	$_____________

Subtotal			$_____________
Shipping & Handling (See Chart )			$_____________
Washington State Tax 8.9% (Orders shipped within Wash St. Only)			$_____________
Order TOTAL			$_____________

Shipping & Handling (continental US only)

Order Amount S & H

1 Bottle $4.00

2 Bottles $5.00

3 to 6 Bottles $7.00
Over 6 Bottles, email or call for quote

Surface (Foreign countries): add $4.00 (USD) to prices above. Please allow eight weeks for your order to arrive.

Air (Foreign countries): add $6.50 (USD) to prices above.

These shipping and handling charges are estimates. In some cases it may be necessary for charges to be adjusted.



DaKara Kies Company is committed to the preservation of the Earth and makes a concerted effort to
 use and reuse recyclable materials.  You may receive you order in an unusual package or with a 
combination of packing materials.  We urge you to reuse whatever you can of the packing materials.

Thank you for your order!

Please email/mail or fax this completed form to the address above or call with your Visa/Mastercard number.

DaKara Kies Company"s order form is non-encrypted and credit card orders are placed at your own risk.
Please read our policy on ordering with your credit card.

Email to: Dakara@Dakara.com

Mail to: Dakara Kies Co
P.O. Box 1354
Marysville, WA 98270
(Orders mailed to the PO Box may incur a delay of shipping of an additional week)

FAX: 425-953-4304

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Chakra Balance Flower Essences Order Form

DaKara Kies Company P.O. Box 1354 Marysville, WA 98270

(425) 267-9738 OR 1-800-813-3877 FAX orders to (425) 953-4304

Print out, complete, and mail this form to the address above or (Orders mailed to the PO Box may incur a delay of shipping of an additional week)