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
1 Bottle EluTan - 45 tablets $9.95 $3.75 $13.70
2 Bottles EluTan - 45 tablets each (You save 10%) $17.90 $3.75 $21.65
3 Bottles EluTan - 45 tablets each (You save 15%) $25.35 $3.75 $29.10
6 Bottles EluTan - 45 tablets each (You save 20%) $47.75 $3.75 $51.50
12 Bottles EluTan - 45 tablets each (You save 25%) $89.55 FREE $89.55
 
 

Mail or fax form with credit card number, check or money order to:
 Netpack
2304 Nostrand Ave #4611
Brooklyn, NY 11210

Tel: 917-841-1600

FAX: 413-460-2932