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Mail-in Order Form


Mail this form to:

Back To Good Health

16534 Silverado Drive

Southgate, Michigan 48195


NAME:________________________________________________________________


COMPANY NAME:_____________________________________________________


ADDRESS:_____________________________________________________________


CITY:__________________________________________________________________


STATE:________________________________________________________________


ZIP CODE______________________________________________________________


COUNTRY_____________________________________________________________


EMAIL ADDRESS:______________________________________________________


*All your information is strictly confidential*


Here is how I will pay:


VISA[ ] MASTER CARD [ ] DISCOVER [ ] AMERICAN EXPRESS [ ]


AMERICAN EXPRESS [ ] BY CHECK [ ] (please enclose- payable to Denise Garcia)


Card #___________________________Expires________________________________


Billing Address:__________________________________________________________


Signature:_____________________ Print name on Card______________________


Telephone #_____________________________


U.S.SHIPPING:


$6.95 for 1 lb. 2 oz. or less: $8.95 for 2 lb. 3 oz. or less: $9.95 for 3 lb. 4 oz or less:


$12.95 for 6 lbs. 8 oz or less: $ 14.95 for 10 lbs. Add .50 cents for each additional pound over 10 pounds.

QTY TOTAL


$117.99 save ($21.00)


PACKAGE A [ ]Popular choice- Convenient pkg.

3 pounds 4 ounces in 13-4 ounce packages _______ / ________ __

________________________________________________________________________________________________


$233.55 save ($35.00)


PACKAGE B [ ]Popular choice- Convenient pkg.

6 pounds 8 ounces-24-4 ounce packages ____ _/______________

________________________________________________________________________________________________


$40.25 save (10.00)


PACKAGE C [ ] Popular choice-Convenient pkg.

1 pound 4-4ounce packages _______ _/______________

________________________________________________________________________________________________


$26.23 save ($13.00)


PACKAGE D [ ] Popular choice-Economical bulk pkg.

1 pound package _________/______________

_______________________________________________________________________________________________


$78.68 save($39.00)


PACKAGE E [ ] Economical bulk pkg.

3-1 pound package _________/_______________

_______________________________________________________________________________________________


$94.35 save ($62.00)


PACKAGE F [ ] Economical bulk pkg.

4-1pound pkgs. __________/______________

_______________________________________________________________________________________________


$234.67 save ($159.00)


PACKAGE G [ ] Economical bulk pkg.

10-1lb. packages ________ /_______________

______________________________________________________________________________________________


$349.99 save ($259.00.00)


PACKAGE H [ ] Economical bulk pkg.

15- 1 pound packages __________/_______________

____________________________________________________________________________________


$499.95 save($561.00)


PACKAGE I [ ] Economical Bulk Package

27.2 lb.package. __________/_______________

______________________________________________________________________________________________


$999.99 save ($1123.00)


PACKAGE J [ ] Economical Bulk Package

54.4 lb. package. __________/_______________

_________________________________________________________________


Sub Total ________/____________


Shipping ________/____________


Total _______/_____________








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