DISTRIBUTOR PRODUCT ORDER FORM
FAX PRODUCT ORDER FORM AND CREDIT CARD PAYMENT FORM
TO 832-533-7446 TOLL FREE (EFAX NUMBER NOT COMPATIBLE WITH HP-100 FAX)
YOU CAN SEND THE PRODUCT ORDER FORM TO 12520 A-1 WESTHEIMER #257, HOUSTON, TEXAS 77077 AND MAKE PAYMENT BY CHECK, MONEY ORDER OR CREDIT CARD TO DAVID BAUMAN ND.
FOR DISTRIBUTORS ONLY
Distributor Name, Address, and Phone
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Heavy Metal Toxicity and Minerals-$195/Unit X Number=
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Male Hormonal Test-$175/Unit X Number=
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Detox Profile-$175/Unit X Number=
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Oxidative Stress(Aging)-$95/Unit X Number=
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TOTAL ORDER
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CREDIT CARD INFORMATION-MASTERCARD, VISA, AMERICAN EXPRESS, DISCOVER CARD
1. NAME
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2. MAILING ADDRESS ASSOCIATED WITH CREDIT CARD INCLUDING ZIP CODE
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3. CREDIT CARD NUMBER AND EXPIRATION DATE
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4..LAST 3 DIGITS ON THE BACK OF CREDIT CARD, IF AMERICAN EXPRESS 4 DIGIT CODE ON FRONT
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