Chemo Diva Order Form Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Phone*Email*Hair Arrival NotificationWe will call or email you when your hair arrives, so you'll know it arrived here safely. Please indicate below if you would prefer to be contacted by phone, or if email is okay. Please call me.Just send an email.Your photoIt is not necessary to send us a photo of your hair style. But if you have one handy, it can be helpful. Plus, we like to "meet" our Chemo Divas!Please enter any comments or concerns here:To Order your Chemo Diva Halo Wig, key in "1" on the quantity field.* Price: $389.00 Quantity: BangsYour halo wig can be made"with" or "without bangs." If you normally do not wear bangs, you will not need them on your halo. For more info go to: About The Halo > Bangs or No Bangs. Add Bangs Turnaround Time*Our regular turnaround time is approx. 10 days. Need it sooner? Choose RUSH ORDER. Regular turnaround, approx 10 days.RUSH ORDER. Your halo ready to ship in 2-3 days.Are your ponies cut according to instruction?Yes, my ponies were cut as instructed. (pinky-thick or smaller, in secure rubberbands)No, my ponies were cut differently.If your hair was bundled in one big pony, we can certainly use it---It just takes a little more time to make your halo. Please do not send loose hair. Is your hair free of oils, odor, or heavy products?*We need squeaky clean hair to make your halo. If it is not, we can clean it before making it. Yes, my hair is clean and dry.No, please clean my hair.How do you want your finished halo wig shipped back to you?Ground UPS $16.002-Day UPS $35.00Overnight UPS $62.00International Mail (for shipping outside of the US) $54.00Payment*You can send a check with your hair, or we can email an invoice to you AFTER your hair arrives. You can pay the invoice on-line with a credit or debit card.Check enclosed.Please send me an invoice.Your email for us to send your invoice.Total $0.00 Do you mind telling me where you heard about us? Thanks!!