Green Supreme-Barley Power

Please provide the following information for your order:

	PERSONAL
First name	*
Middle initial
Last name	*
Street address
Address (cont.)
City
State/Province
Zip/Postal Code
Phone
FAX
E-mail	*

QTY DESCRIPTION

AMOUNT



200 Tablet Bottle Barley Power $17.99

400 Tablet Bottle Barley Power $27.99



200 Tablet Bottle Barley plus Cayenne      $17.99

400 Tablet Bottle Barley plus Cayenne      $27.99



150 Tablet Bottle Barley with Chromium Picolinate $17.99

300 Tablet Bottle Barley with Chromium Picolinate $27.99



90 Veggie Capsules Petal Soft $29.95



*SHIPPING TOTAL

* Shipping charges for orders shipped outside the United States will be charged the actual shipping amount based on the country destination. The shipping amount reflected here DOES NOT reflect the exact shipping total for locations outside the United States. Please call our office to get the exact shipping amount that will be added to your order for shipments outside the United States.

* The below shipping prices are good for orders shipped within the United States ONLY:

SMALL BOTTLES:

For the 1st Bottle:
$3.00

For Each Additional Bottle:
$2.50

LARGE BOTTLES:

For the 1st Bottle:
$4.00

For Each Additional Bottle:
$3.00

                                                           TOTAL



BILLING

Name on card:

Card number:

Card type:

Expiration date: /

CVV number: last three digits on back of card

             Call Me For The Card Information



SHIPPING

Street address:

Address (cont.):

City:

State/Province:

Zip/Postal code:

You can also order by calling us at:
800-358-0777

PRICES

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QTY	DESCRIPTION			AMOUNT


		200 Tablet Bottle Barley Power	$17.99
		400 Tablet Bottle Barley Power	$27.99


		200 Tablet Bottle Barley plus Cayenne	$17.99
		400 Tablet Bottle Barley plus Cayenne	$27.99


		150 Tablet Bottle Barley with Chromium Picolinate	$17.99
		300 Tablet Bottle Barley with Chromium Picolinate	$27.99


		90 Veggie Capsules Petal Soft	$29.95


		*SHIPPING TOTAL
		* Shipping charges for orders shipped outside the United States will be charged the actual shipping amount based on the country destination. The shipping amount reflected here DOES NOT reflect the exact shipping total for locations outside the United States. Please call our office to get the exact shipping amount that will be added to your order for shipments outside the United States.
		* The below shipping prices are good for orders shipped within the United States ONLY:
		SMALL BOTTLES:
		For the 1st Bottle:	$3.00
		For Each Additional Bottle:	$2.50

		LARGE BOTTLES:
		For the 1st Bottle:	$4.00
		For Each Additional Bottle:	$3.00

	TOTAL

	BILLING
Name on card:
Card number:
Card type:
Expiration date:	/
CVV number:	last three digits on back of card
Call Me For The Card Information

	SHIPPING
Street address:
Address (cont.):
City:
State/Province:
Zip/Postal code: