| Full
Name:_____________________________________________________ |
| Street
address :_________________________________________________ |
| ______________________________________________________________ |
| Phone:____________________
Fax: ____________________________ |
| E-mail:_________________________ |
| Neu-Becalm'd Order: |
Retail: |
Quantity: |
| Encore Optima
-90 Tabs |
$27.00 |
______ |
| Neu-Becalm'd Chewable
-90 Tabs |
$35.50 |
______ |
| Neu-Becalm'd 90 Chewable
(4 Pack $31.50 per bottle) |
$126.00 |
______ |
| Neu-Becalm'd
-90 Cap |
$37.50 |
______ |
| Neu-Becalm'd 90 Cap
(4 Pack $33.25 per bottle) |
$133.00 |
______ |
| Neu-Relieve 180
Cap |
$69.95 |
______ |
| Neu-Recover 180
Cap |
$69.95 |
______ |
| Neu-Replenish
180 Cap |
$69.95 |
______ |
| Neu-Slim -
180 Cap |
$69.95 |
______ |
| * Include
shipping and handling. |
S
& H |
______ |
| |
Total:
|
______ |
|
Shipping and Handling |
| 1-4 Bottles |
$10.50 |
|
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:________________________________________________________ |
| ________________________________________________________________ |
|