| Full
Name:_____________________________________________________ |
| Street
address :_________________________________________________ |
| ______________________________________________________________ |
| Phone:____________________
Fax: ____________________________ |
| E-mail:_________________________ |
| Becalmd Order: |
Retail: |
Quantity: |
______ |
| Neu-Becalm'd Chewable
-90 Tabs |
$40.50 |
______ |
| Neu-Becalm'd 90 Chewables
(4 Pack $36.00 per bottle) |
$144.00 |
______ |
| Neu-Becalm'd
90 Cap |
$42.50 |
______ |
| Neu-BeCalm'd 90 Cap
(4 Pack $37.75 per bottle) |
$151.00 |
______ |
| Neu-Relieve 90 Cap |
$39.00 |
______ |
| Neu-Recover 90
Cap |
$42.50 |
______ |
| Neu-Replenish
90 Cap |
$42.50 |
______ |
| Neu-Slim -
90 Cap |
$43.50 |
______ |
| * Include
shipping and handling. |
S
& H |
______ |
| |
Total:
|
______ |
|
Shipping and Handling |
| 1-8 Bottles |
$8.00 |
| 9-12 Bottles |
$12.00 |
|
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:________________________________________________________ |
| ________________________________________________________________ |
|