|
Name*:_________________________________________________________________
Address*:_______________________________________________________________
City*:_________________________________ State*:______
Zip*:________________
Phone:______________________Email:______________________________________
Credit Card#
(optional):__________________________exp.date:____________ 
*Required Field
|
Quantity |
Price Each |
Total |
|
Active 8 BH BL Diet Plan with Supplements and
Drinks: |
|
|
|
|
|
|
|
|
30 Chocolate Protein Drinks |
____________ |
$159.95 |
____________ |
|
|
|
|
| 30 Vanilla Protein Drinks |
____________ |
$159.95 |
____________ |
|
|
|
|
| 30 Strawberry Protein Drinks |
____________ |
$159.95 |
____________ |
|
|
|
|
|
10 ea. Choc/Van/Straw Protein Drinks |
____________ |
$159.95 |
____________ |
|
|
|
|
| 15 ea. Chocolate/Vanilla Protein
Drinks |
____________ |
$159.95 |
____________ |
|
|
|
|
| 15 ea. Chocolate/Strawberry Protein
Drinks |
____________ |
$159.95 |
____________ |
|
|
|
|
|
15 ea. Vanilla/Strawberry Protein
Drinks |
____________ |
$159.95 |
____________ |
|
|
|
|
|
|
|
|
|
Supplements Only: |
|
|
|
|
|
|
|
| Supplement #1 |
____________ |
$34.95 |
____________ |
| Supplement #2 |
____________ |
$29.95 |
____________ |
| Supplement #3 |
____________ |
$29.95 |
____________ |
|
|
|
|
|
Protein Drinks Only: |
|
|
|
|
|
|
|
|
30 Chocolate |
____________ |
$69.95 |
___________ |
|
30 Vanilla |
____________ |
$69.95 |
___________ |
|
30 Strawberry |
____________ |
$69.95 |
___________ |
|
15 ea. Chocolate/Vanilla |
____________ |
$69.95 |
___________ |
|
15 ea. Chocolate/Strawberry |
____________ |
$69.95 |
___________ |
|
15 ea. Vanilla/Strawberry |
____________ |
$69.95 |
___________ |
|
10 ea. Choc/Van/Straw |
____________ |
$69.95 |
___________ |
|
|
|
|
|
|
SUBTOTAL |
___________ |
|
Shipping & Handling For Orders Totaling:
|
|
|
Less than $40 ADD:
|
$4.95 |
____________ |
|
$40.01 - $65 ADD: |
$5.95 |
____________ |
|
$65.01 - $100 ADD: |
$7.95 |
____________ |
|
over $100 ADD: |
$11.95 |
____________ |
|
OK residents
only-please add 8.375% |
Sales
Tax |
____________ |
| |
|
TOTAL |
|
|
