Ameriden Preferred Client Program Sign-Up Form

Please complete the following form to sign up. Thank you!

BILLING INFORMATION:
CARD INFORMATION *

SHIPPING INFORMATION: (If different than billing)
PROGRAM DETAILS: (please choose one)

MONTHLY AUTO-SHIP ORDER DETAILS: (Please select the products to be shipped to you monthly)
Product Name Quantity X Unit Price = Totals
Ameriden® Products
The Original Olive Leaf Extract® - 90 Capsules, 525 mg each X $32.95 =
Rosavin™ - 60 Capsules, 100 mg each X $20.95 =
Rosavin Plus® - 90 Capsules, 150 mg each X $27.95 =
Clear-Mind® - 60 Capsules, 275 mg each X $39.95 =
EZ-Energy® Athletic Formula - 60 Capsules, 600 mg each X $38.95 =
Beta Factor® - 60 Capsules, 500 mg each X $65.95 =
Bio-Antihist® - 90 Capsules, 350 mg each X $32.95 =
GlucoRite™ - 90 capsules 710 mg X $54.95 =
Nu-Flex® - 90 Capsules, 775 mg each X $39.95 =
Xtreme Tasteez™ 3 flavors, 30 Packs, 5 grams each X $19.95 =
Creation's Garden Products
Advanced Digestive Enzymes - 60 ct X $18.00 =
Beta Sitoserol - 60 ct X $7.00 =
Blood Cleanse - 100 ct X $16.00 =
Bowel Cleanse - 100 ct X $16.00 =
Candida Relief - 100 ct X $28.95 =
Carb Blocker - 60 ct X $14.00 =
CoQ10 - 60 ct X $24.00 =
Fat Neutralizer - 120 ct X $18.00 =
Liver Cleanser - 100 ct X $16.00 =
Maximum Male Performance - 30 ct X $14.00 =
Mega Vitamin C - 100 ct X $14.00 =
Omega 3,6,9 Essential Fatty Acids - 100 ct X $26.00 =
Parasite Cleanse - 100 ct X $18.00 =
Prostate Factor Plus - 100 ct X $24.00 =
Sleep Induce - 60 ct X $17.00 =
4 in 1 Weight Loss - 60 ct X $19.50 =
Vegan Protein Powder - 20.04 oz X $28.00 =
Vitamin B12 - 110 ct X $8.00 =
Vitamin D Cream - 2 fl oz X $12.00 =
Vitamin Mineral Drink - 32 oz X $16.00 =
Hand Sanitizer - Cucumber - 2 fl oz X $2.00 =
Hand Sanitizer - Lemongrass - 2 fl oz X $2.00 =
Hand Sanitizer - Peach - 2 fl oz X $2.00 =
Hand Sanitizer - Pomegranate - 2 fl oz X $2.00 =
Hand Sanitizer - White Tea - 2 fl oz X $2.00 =
Product SUBTOTAL:
Preferred Customer SAVINGS:
MONTHLY TOTAL: