Order Form For Hair System (Repairs)
(Print & mail with system)

Name ___________________________________
Date _________________
Address _________________________________
City __________________________ State__________ Zip Code________ Country________
Area Code and Phone Number (____)______________ E-Mail Address__________________________
Contact Name _________________________
Short Description of System sent to Duplicate __________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

Hair Type Desired: Synthetic:______________ % Human:______________ %
Style: Please indicate one:

Wave Or Curl Pattern: (examples) Body Wave___ Slight Wave___ Medium Wave___ Tight Wave___ Medium Curl___ Tight Curl___ Finished Hair Density: Light___ Medium___ Heavy___ Other___________________ Finished Hair Length:________ (Maximum finished length is 7" with no extra charge) Match color to System Yes___ No___ Scotch Tape Large Hair Samples in appropriate boxes.(how to take hair samples)

2 LEFT TEMPLE . . .

4 BEHIND LEFT EAR . . .

2 RIGHT TEMPLE . . .

4 BEHIND RIGHT EAR . . .

1 FRONT . . . .

3, 5 TOP . . . .

6 BACK . . . .

Special Requests: ________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________

Repair Cost is $150.00 + $10.00 shipping per unit: Total $________
Remy hair, European hair and longer lengths are additional half price of a new system.
Please check one below:
[ ] Visa [ ] Mastercard [ ] Amex [ ] Discover [ ] Check [ ] Money Order
(If CC order) Print Name___________________________________________
Account #: ___________________________________________
Expire Date: _____________________ CVV#: ______________
Card Holder Signature __________________________________
Expect Delivery in approximately 4-5 weeks. No refund