| Full Name:_____________________________________________________ |
| Street address :_________________________________________________ |
| ______________________________________________________________ |
| Phone:____________________ Fax: ____________________________ |
| E-mail:_________________________ |
| Becalmd Order: | Retail: | Quantity: |
| beCALM'd -90 Cap | $42.50 | ______ |
| beCALM'd Chewable -90 Tabs | $40.50 | ______ |
| Neu-Recover 90 Cap | $42.50 | ______ |
| Neu-Replenish 90 Cap | $42.50 | ______ |
| Neu-Relieve 90 Cap | $39.00 | ______ |
| Neu-Slim - 90 Cap | $43.50 | ______ |
| * Include shipping and handling. | S & H | ______ |
| | Total: | ______ |
| Shipping and Handling | | 1-6 Bottles | $8.00 | | 7-12 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:________________________________________________________ |
| ________________________________________________________________ |
|