| Full Name:_____________________________________________________ |
| Complete Shipping
Address (Include ZipCode)________________________________________ |
| ____________________________________________________________________________ |
| Phone:
(Required)____________________
Fax: ____________________________ |
| E-mail: (Required) _________________________________ |
| Social Security Number or U.S. Federal E.I.N.:______________________________
(Not required for first order.) |
| Optional
-
Company Name:______________________________ |
| Shipping
address (if different):________________________________________________ |
| Monthly Auto-Ship Order: |
Price Each: |
|
Price (X) Qty.: |
|
Neu-Becalm'd (Formerly beCALM'd) -90 Capsules |
$27.50 |
|
______ |
| Chewable
Neu-Becalm'd - (90 Sub-lingual Tablets) |
$25.50 |
|
______ |
|
(4 Pack $37.00 per bottle) FREE SHIPPING |
$108.00 |
|
______ |
|
Neu-Becalm'd -90 Cap 12 bottle
case.
FREE SHIPPING |
$294.00 |
|
______ |
|
NeuReplenish (Formerly NeuRecover-SA) 180 Capsules |
$56.50 |
|
|
|
NeuRecover (Formerly NeuRecover-DA) 180 Capsules |
$56.50 |
|
______ |
|
NeuRelieve (Formerly NeuRecover-BZ) 180 Capsules |
$56.50 |
|
|
| NeuSlim
(Formerly NeuroSlim) - 180 Capsules |
$56.50 |
|
______ |
| (Enter Other Product): |
|
|
|
| (Enter Other Product): |
|
|
|
| Distributor
Kit (Required to become active in business.) |
$29.95 |
|
$29.95 |
| * Include shipping and handling. |
|
S
& H |
______ |
| |
|
Total: |
______ |
*Shipping and Handling (Express mail (USA Only) 1 Bottle - $13.85, 2-10 Bottles $17.85) |
| 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.
Please call 800-862-5033 for an exact quote. |
Outside of USA shipping prices will vary accordingly. |
|
| Credit
Card Information: |
| Card Type: (Please Circle) VISA, MasterCard, Discover, American Express |
| Card Number:________________________________ |
| Expiration Date:___________
Card Verification Number (3 Digit on rear of card)______ |
| Name on Card:__________________________________
|