PROBIO BLEND -- ORDER FORM

Name   

 Address 
 City, State & Zip
Phone  

 Work Phone    
E-mail

Type of Credit Card    

VISA  MasterCard Discover AMEX

CC#

Exp Date/        Security Code

Signature _____________________________________________________________

PRICE  --  

$23.00 (2 months supply)

$46.00 (2 bags)

$69.00 (3 bags)

SHIPPING  -- 

$  4.00 (1 bag)

$  5.00 (2 bags)

$  6.00 (3 bags)

Order TOTAL -- 

$27.00

$51.00

$75.00

PRICE  --  

$92.00 (4 bags)

$115.00 (5 bags) $138.00 (6 bags)

SHIPPING  -- 

$  7.00 (4 bags)

$    7.50 (5 bags) $    8.00 (6 bags)

Order TOTAL -- 

$99.00

$122.50

$146.00

PRICE  --  

$161.00 (7 bags)

$184.00 (8 bags)

$207.00 (9 bags)

SHIPPING  -- 

$    8.50 (7 bags)

$    9.00 (8 bags)

$    9.50 (9 bags)

Order TOTAL -- 

$169.50

$193.00

$216.50

PRICE  --  

$230.00 (10 bags)

SHIPPING  -- 

$  10.00 (10 bags)

Order TOTAL -- 

$240.00

Mail completed form & check or money order made payable to: (Credit Cards Accepted)
Teresa Balkcum
10420 New Town Rd
Waxhaw, NC  28173