| Full
Name:_____________________________________________________ |
| Street
address :_________________________________________________ |
| ______________________________________________________________ |
| Phone:____________________
Fax: ____________________________ |
| E-mail:_________________________ |
| Product Name: |
Retail: |
Quantity: |
| Neu-Becalm'd
90 Cap |
$37.50 |
______ |
4-Neu-BeCalm'd
(Free Encore!) |
$135.00 |
______ |
| Neu-Becalm'd Chewable
-90 Tabs |
$35.50 |
______ |
4-Neu-Becalm'd Chewables
(Free Encore) |
$128.00 |
______ |
| Encore Optima
-60 Cap |
$27.00 |
______ |
3-Encore Optima
(Plus 1-Free Encore) |
$73.50 |
______ |
| Neu-Relieve 90
Cap |
$34.00 |
______ |
4-Neu-Relieve
(Free Encore) |
$122.00 |
______ |
| * Include
shipping and handling. |
S
& H |
______ |
| |
Total:
|
______ |
International Priority
| Canada |
United Kingdom | All Others |
| $8.00 |
$10.00 | $12.00 |
Global Express
| Canada |
United Kingdom | All Others |
| $21.00 |
$30.00 | $30.00 |
|
|
All prices are in US dollars.
|
| Card
Type:___________________________________ |
| Card
Number:________________________________ |
| Expiration
Date:___________ |
| Name
on Card:__________________________________ |
| Message:________________________________________________________ |
| ________________________________________________________________ |
|