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

125.13 save (10.00)

PACKAGE A [ ]Popular choice- Convenient pkg.

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

230.26 save (10.00)

PACKAGE B [ ]Popular choice- Convenient pkg.

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

42.89 save (10.00)

PACKAGE C [ ] Popular choice-Convenient pkg.

1 pound 4-4ounce packages _______ _/______________
________________________________________________________________________________________________

229.97 save (163.40)

PACKAGE D [ ] Popular choice-Economical bulk pkg.

10 pounds 10-1 pound packages _________/______________
_______________________________________________________________________________________________

33.89

PACKAGE E [ ] Economical bulk pkg.

1 pound package _________/_______________
_______________________________________________________________________________________________

108.67 save (20.00)

PACKAGE F [ ] Economical bulk pkg.

3-1pound pkgs.1-4ounce pkg __________/______________
_______________________________________________________________________________________________

459.87 save (210.00)

PACKAGE G [ ] Economical bulk pkg.

27pounds 2 ounce bag ________ /_______________
______________________________________________________________________________________________

99.97 save (84.00)

PACKAGE H [ ] Economical bulk pkg.

4- 1 pound pkgs. __________/_______________
____________________________________________________________________________________

53.37
PACKAGE I [ ] Specialty package

1 pound 16-1ounce pkgs. __________/_______________
______________________________________________________________________________________________

108.20 save $10.00

PACKAGE J [ ] Specialty package

2 pounds 3 ounces 35-1 ounce pkgs. __________/_______________

Sub Total ________/____________

Shipping ________/____________

Total _______/_____________