Fax/Check - Retail Order
Form
Print and Fax this
document to:
281-332-4753 Or mail it to:
NeuroGenesis, Inc., 120 Park
Avenue, League City, TX
77574
SPONSOR INFO: Fred & Lynn
(5495)
| Full Name:_____________________________________________________ | ||
| Complete Address (Including ZipCode)______________________________ | ||
| ______________________________________________________________ | ||
| Phone:____________________ Fax: ________________________________ | ||
| E-mail: (Important)(Please Check Accuracy)__________________________ | ||
Product: |
Retail: | Number Of Bottles Multiplied By Price: |
| Neu-Becalm'd (Formerly beCALM'd) -90 Capsules | $37.50 | ______ |
|
Chewable Neu-Becalm'd - (90 Sub-lingual Tablets) |
$35.50 | ______ |
| beCALM'd - (4 Pack $37.00 per bottle) FREE SHIPPING | $148.00 | ______ |
| NeuReplenish (Formerly NeuRecover-SA) 180 Capsules | $69.95 | ______ |
| NeuRecover (Formerly NeuRecover-DA) 180 Capsules | $69.95 | ______ |
| NeuRelieve (Formerly NeuRecover-BZ) 180 Capsules | $69.95 | ______ |
| NeuSlim (Formerly NeuroSlim) - 180 Capsules | $69.95 | ______ |
| (Enter Other Product): | ______ | |
| (Enter Other Product): | ______ | |
| (Enter Other Product): | ______ | |
| * Include Shipping and Handling. | Shipping | ______ |
| Total: | ______ | |
*Shipping and Handling |
||
| Shipping & Handling (USA) | US $ | |
| 1-2 Bottle (s) | $6.00 | |
| 3-5 Bottles | $6.30 | |
| 6-7 Bottles | $8.55 | |
| 8-9 Bottles | $8.80 | |
|
Incremental over 9 bottles or outside of
USA. |
||
Outside of USA shipping prices will vary accordingly.. |
||
| Circle card Type: ( Visa, MasterCard, Discover, or American Express) | ||
| Card Number:________________________________ | ||
| Expiration Date:________ Card Verification Number (3 Digit on rear of card) ______ | ||
| Name on Card:__________________________________ | ||
| Signature of Card Holder:____________________________________________ | ||
| Message: (If Any)__________________________________________________ | ||
| Make Checks & Money Orders (U.S. Dollars) Payable To: NeuroGenesis, Inc. | ||