BrainAlert Mail Order Form

Step 1 – Order Information:

   -----------------------------------------------------
  |  Retail price $49.95                                |
  |                                                     |
  |  Price $29.95 per bottle                            |
  |_____________________________________________________|
  |                                                     |
  |  [ ] 1 bottle        $29.95 . . . . . . .  ________ |
  |                                                     |
  |  [ ] 2 bottles       $59.90 . . . . . . .  ________ |
  |                                                     |
  |  [ ] 3 bottles       $89.85 . . . . . . .  ________ |
  |                                                     |
  |                     subtotal  . . . . . .  ________ |
  |_____________________________________________________|
  |                                                     |
  |   Shipping and handling . . . . . . . . .    Free   |
  |                                                     |
  |   Tax – apply to WA residents only . . . . ________ |
  |         (subtotal times 0.095)                      |                      
  |                                                     |
  |                                Total . . . $_______ |
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Step 2 - Payment Method:
   _         _                                    
  |_| Visa  |_| MasterCard  
   _                                
  |_| Money Order/Check payable to BrainAlert LLC

  Card #______________________________________ Exp.___/___

  Name (as it appears on card):____________________________________

  Email Address: ___________________________________________________

  Phone number: ______________________________

Step 3 - Billing Information:

  First Name:___________________________

  Last Name:____________________________

  Address: ________________________________________________________

  Address 2: ______________________________________________________

  City:___________________ State:______ Zip code:_________

Step 4 – Shipping Information: (leave blank if same as billing)
 
  First Name:__________________________
 
  Last Name:___________________________

  Address:_________________________________________________________

  Address 2:_______________________________________________________

  City:__________________ State:_____ Zip (or postal code):________

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   Mail this order form to:    BrainAlert LLC                       
                              18126 NE 201st DR.                    
                            Woodinville, WA  98077
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