Wholesale Distributor Application

 

  

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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/