StopJetLag™ Plan Order Form
Please print and fill out the form below, sign it, attach a copy
of your flight itinerary with all connecting flights, and return it to our order
department via Fax (650-851-2457) or Postal Mail. If you are having
difficulty printing the form, please contact the order department at 650-851-4484.
Postal Mail:
StopJetLag Travel Service
Attention: StopJetLag Plan
12672 Skyline Blvd.
Woodside, CA 94062 USA
FAX: 650-851-2457
StopJetLag Plan Order Info
Please fill out the following address information, confirm your normal
personal living patterns, and attach a copy of your flight itinerary
with all connecting flights.
Name (First, Last): _____________________________________________________
Company: ________________________________________________________________
Mailing Address: ________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
E-mail address: _________________________________________________________
Telephone No.: ________________________ Fax: __________________________
(Your fax number is the preferred method of delivery)
Normal Living Pattern (modify if necessary)
Normal Meal Times:
Breakfast (7:00 am): _______ Lunch (12:00 noon): _______ Supper (7:00 pm): _______
Normal Sleep Pattern:
Bedtime (10:30pm): ____________ Wake-up at (6:30 am) _____________
I regularly drink caffeinated beverages (Yes/No) : _______
Evening caffeine keeps me awake past my normal bedtime (Yes/No): ______
(Assume Yes if a non-caffeine drinker)
I request my StopJetLag Plan include recommendations
for using melatonin supplements (Yes/No): ______
StopJetLag Plan: __ $25.00 __
Express Charge ($10.00): ____________
For International Orders add ($5.00): ____________
Total: ____________
Note: Itineraries received within 10 days of travel are subject to
a $10 express processing fee.
Credit Card (check one)
___ Visa ___ MasterCard ___ Amex ___ Check
Credit Card No. ___________________________________ Exp Date ____________
Name (First, Last): _____________________________________________________
(Enter "SAME" if Billing Address is the same as the Mailing Address)
Company: ________________________________________________________________
Billing Address: ________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
I authorize StopJetLag Travel Service to charge the above credit
card for this StopJetLag Plan order.
Signature: ____________________________________________ Date: ___________
Questions regarding the required information for the StopJetLag
Plan should be sent to moc.galtejpots@70ofni.
All material © Copyright 2007 StopJetLag Travel Service
Rev: A070311
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