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. __________/_______________
_________________________________________________________________
$50.75
PACKAGE K [ ] Specialty Package
1 lb.- 16-1ounce packages
__________/_______________ _________________________________________________________________
$98.48 PACKAGE L [ ] Specialty Package
2lb. 3ounces
35-1ounce packages
__________/_______________ _________________________________________________________________
Sub Total ________/____________
Shipping ________/____________
Total _______/_____________
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