NeuroGenesis Distributor Sign-up

(SSN or Fed. ID #'s are required for US and Canada to receive wholesale price.)

Contact Information

E-mail Address:
Full Name:
Phone Number:
Address:
City
State:		ZIP:
Country (If outside USA)

Co-Applicant Information:	First Name:	Last Name:

Shipping address:

(if different)

You agree to auto-ship of at least two (2) $27.50 bottles per month
or any 1 bottle that meets the minimum monthly auto-ship value of $55.00
(Auto-ship is the date of your original order date for every month).

For Distributorship 2 Bottles Minimum Monthly:	Auto Ship
beCALM'd - 90 Caps.	$27.50
beCALM'd - 90 Caps. (4 Pack $27.00 per bottle)	$108.00
beCALM'd - 90 Caps. (Case 12 Bottles $24.50 per bottle)	$294.00
beCALM'd Children's Chewable - 90 Tabs.	$25.50
Neu-Replenish 180 Caps.	$56.50
Neu-Relieve 180 Caps.	$56.50
Neu-Recover 180 Caps.	$56.50
NeuroSlim - 180 Caps.	$59.95
Distributor Signup Kit -16 page distributor manual, product brochures, audio tape, CD, Studies, Sign-Up Pages: Retail, Preferred Customer, Distributor & more. Marked for distributor kit.	Signup: $29.95

Shipping and Handling
1-4 Bottles	$6.00
5-8 Bottles	$8.00
9-12 Bottles	$12.50
Over 12 bottles or outside of USA shipping prices will vary. Express mail (USA Only) 1 Bottle - $16.00, 2-4 Bottles $20.00 select here

Method of payment:

Credit Card

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Card Number:

Expiration Date:

Card ID Number : 3 digit ID number on back of card, 4 Digit for American Express

Your Name on Card:

Card address "If Different":

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