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PRODUCT ORDER INFORMATION

Please list the quantities of the products you would like to order.
VIYM™ Visually Impaired Yoga Mat - $75 (Plus $5 Handling)

Orders of 6 or more mats will receive a 10% discount.
VIYM™ DVD Series 1 - $12 (Plus $2 Handling)

Orders of 6 or more will receive a 10% discount.
VIYM™ DVD Series 2 - $12 (Plus $2 Handling)

Orders of 6 or more will receive a 10% discount.
CUSTOMER BILLING INFORMATION

Please enter your billing information exactly as it appears on your credit card statement.
Name * First Last
Company / Organization
Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Number * ### - ### - ####
Email *
Credit Card Type *
Visa Mastercard American Express Discover
Credit Card Number *
Expiration Date * MM / DD / YYYY
Security Code *
SHIPPING INFORMATION

Please provide the address where you'd like us to ship your products.
Is Your Shipping Address Different From Your BIlling Address? *
Yes No

If yes, please fill out your shipping address below. If no, ignore this section and proceed to the bottom of the form.
Name First Last
Company / Organization
Address (Note: We cannot ship to a P.O. Box)
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

PLEASE NOTE: We cannot ship to a P.O. Box
Phone Number ### - ### - ####
Email
Email List

Please indicate if you'd like to be a part of our email list. Don't worry, we won't spam you.
Yes, put me on the e-list No thanks, don't put me on the e-list
Thanks for Ordering From Rousettus!

We sincerely appreciate your business. Please don't hesitate to contact us with any questions or concerns.
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PRODUCT ORDER INFORMATION

CUSTOMER BILLING INFORMATION

SHIPPING INFORMATION

Email List

Thanks for Ordering From Rousettus!