Wholesale Distributor Application
 

  

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IMPORTANT: Use Tab key, or mouse, to move between form fields. 
Enter key will exit the form, and you must start over.

First name
Last name
Postal Address

Apt., Suite, etc.
City
State / Province
Postal (Zip) code
Country
Phone 123-456-7890
E-mail (Required)
Name on Card
    (If Different)
Card Number All Credit & Debit  (No dashes)
Expiration Date 04/11
CVN Number Three digit code on back of card. (AMEX=4digit)
Tax ID Social Security / EIN
Sponsor:
VERY
IMPORTANT

Sponsor:

NGI ID#

Co-Applicant:
(If Applicable)
Enter quantity for each item. US $

Neu-Becalm'd - 90 Capsules (Normalize Brain Chemistry)

  27.50
Neu-Becalm'd (Case) - 90 Caps (12 Bottles) $24.50/ea

294.00
Neu-Becalm'd Chewables  - 90 Sublingual Tablets  25.50

Neu-Recover  -  Depressant Recovery  (DA) - 90 Capsules

 27.50
Neu-Replenish  - Stimulant Recovery  (SA) - 90 Capsules  27.50
Neu-Relieve  -  Benzo's Recovery  (BZ) - 90 Capsules 26.75

Neu-Slim  -   Stop Carbohydrate Cravings  - 90 Capsules

 28.50
Wholesale / Distributor Kit. (If new, kit required) Choices below.
   Hard Copy Kit (Plus  s/h  -  US= $15,  Elsewhere $28+) 29.95 + s/h
   Virtual Download Kit (No shipping charge!) (Default Kit if none specified) 20.00
   Autoship this order each month. Best Choice!
   Express mail (USA Only) Averages $25  (Buy another bottle instead.) Bad Choice
Enter anything else you want us to know in this text box.
 If you want it shipped to a different address, or to designate a placement distributor, etc. enter it here.

Please VERIFY that you have filled in everything correctly.  

Click only ONCE and wait for a confirmation web page.
You will also receive a confirmation e-mail message.
Invoice available online upon NGI acceptance,
usually within one business day.

USA Shipping  ESTIMATES

1-3 Bottles $7.25 6-7 Bottles $8.55
4-5 Bottles $7.75   8-9 Bottles $8.90+

Invoice will be available online upon NeuroGenesis Inc. acceptance.
Your NGI ID# will be emailed at that time, along with needed info.
Over 9 bottles or outside of USA shipping prices will vary accordingly.

NeuroGenesis, Inc.
120 Park Avenue
 League City, TX 77573 
800-862-5033

"Saving the world, one brain at a time."

This page url: http://www.NeuroGenesis.biz
This page secure url: https://secure.ADHDrelief.com/~neuroge1/