Instructions: Print or hand copy this page, Fill in the form, Mail to the address on the bottom of form
 

Name___________________________________

Email___________________________________

Address__________________________________

City/State/Zip____________________________

Phone # :_____________________________

Payment: [ ]Check [ ]Money Order
[ ] Master Card [ ]Visa [ ]Discover [ ]American
Express

Card No:___________________Exp.______

Signature:_____________________________

 
Order Information
Item Price Shipping Total
geniCiL™ FBC- Diet formula
Please ship me:
Price
geniCiL™ FBC - 30 day supply
$39.00
geniCiL™ FBC - 60 day supply (save 10%)
$70.20
geniCiL™ FBC - 90 day supply (save 15%)
$99.45
geniCiL™ FBC - 120 day supply (save 20%)
$124.80
 
 
Mail or fax form with credit card number, check or money order to:
NetPack
2304 Nostrand Avenue
Department 4611
Brooklyn, NY 11210
 

FAX: 413-460-2932