Order Form - Flower Essences

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

(425) 267-9730 OR 1-800-813-3877 FAX 425-953-4304

Print out, complete, and mail this form to the address above

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

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)

For Personal Flower Essence Blend list your name(s) or pet/animal name(s). (Use an additional sheet if necessary)

______________________________             _______________________________

______________________________             _______________________________

Briefly explain any issue(s) you would like to address, i.e. depression, self esteem, anxiety, etc. (It is not necessary to list anything as your High Self will know what needs to be addressed.)

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

HOLD HARMLESS AGREEMENT

I the undersigned, understand that Flower Essences and Gem Elixirs are not a medical substitute for any physical ailments that I may have a this time and that I have or will consult a Licensed Professional. I furthermore, hold harmless Wendy Lloyd or DaKara Kies Company from any liability and I take complete responsibility for my personal well being.

Signature: _________________________________

Date: ______________________________

If the Flower Essence blend is for a pet/animal please complete Pet Profile and mail it with this form.

Personal Flower Essence Blends come in a 1 fl oz. (30 ml) Blue Cobalt bottle. Each one will generally have 5 to 10 essence's. Cost $35.00 USD each. Information on the essences used will be included with your shipment. For pets/animals the information varies and may not seem directly related. Some information is available for animals and will be included, if it applies.

Planetary Earth Change Essence Available in 1/2 fl. oz. Concentrate $19.95 and 1 fl. oz. Dosage $15.95. to order click here

Chakra Balance Essences Three Formulas: Ground and Release, Divine Love, Awaken to Spirit,
Available in 1/2 fl. oz. Concentrate $16.95, 1 fl. oz. Dosage $12.95, 2 fl. oz. to order click here

Dakara's Calming Essence for Pets is available in a 1 fl. oz. (30 ml) Dosage bottle (used directly in the mouth, on paw pads or in water bowl) $12.95. also available 2 fl.oz. (60 ml) Spray Mist $12.95

Dakara's Calming Essence is available in a 1 fl. oz. (30 ml) Dosage bottle $12.95.

All Funds USD

Item Description	Qty	Price	Total
Personal Flower Essence Blend	____	$35.00	$_____________
Dakara's Calming Essence for Pets Dosage 1 fl. oz.	____	$12.95	$_____________
Dakara's Calming Essence for Pets Spray 2 fl. oz.	____	$12.95	$_____________
Dakara's Calming Essence - Dosage 1 fl. oz.	____	$12.95	$_____________

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.

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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