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
Apple Cider Vinegar Diet



1 Month Supply(you save $10)
2 Month Supply(you save $25)
3 Month Supply(you save $40)
6 Month Supply(you save $90!)
12 Month Supply(you save more than $200!!)
 $14.95
$24.90
$34.85
$59.70
$95.40

$4.05
$6.10
$7.15
$9.30
$12.60

 $19.00
$31.00
$42.00
$69.00
$108.00
 
 

Mail or fax form with credit card number, check or money order to:
 NetPack
2304 Nostrand Avenue
Department 4611
Brooklyn, NY 11210

TEL: 917-841-1600

FAX: 413-460-2932