| Full
Name:_____________________________________________________ |
| Street
address :_________________________________________________ |
| ______________________________________________________________ |
| Phone:____________________
Fax: ____________________________ |
| E-mail:_________________________ |
| Becalmd Order: |
Retail: |
Quantity: |
| Neu-Becalmd
-90 Cap |
$37.50 |
______ |
| Neu-Becalmd 90 Cap
(4 Pack $37.00 per bottle) |
$133.00 |
______ |
| Veggie Caps
-90 Cap |
$38.50 |
______ |
| Neu-Becalmd Chewable
-90 Tabs |
$35.50 |
______ |
| NeuReplenish
180 Cap |
$69.95 |
______ |
| NeuRecover 180
Cap |
$69.95 |
______ |
| NeuRelieve 180
Cap |
$69.95 |
______ |
| Neu-Slim -
180 Cap |
$69.95 |
______ |
tr>
Encore Optima -
60 Cap |
$27.00 |
______ |
| * Include
shipping and handling. |
S
& H |
______ |
| |
Total:
|
______ |
|
Shipping and Handling |
| 1-4 Bottles |
$7.10 |
| 5-8 Bottles |
$10.50 |
| 9-12 Bottles |
$15.00 |
|
Over 12 bottles or outside of USA shipping
prices will vary. |
|
|
All prices are in US dollars.
|
| Card
Type:___________________________________ |
| Card
Number:________________________________ |
| Expiration
Date:___________ |
| Name
on Card:__________________________________ |
| Message:________________________________________________________ |
| ________________________________________________________________ |
|