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
AmeriZyme® - 90 Capsules, 487 mg each® X $36.95 =
Beta Factor® - 60 Capsules, 500 mg each X $65.95 =
Bio-Antihist® - 90 Capsules, 350 mg each X $32.95 =
Blood Purifier BL-PUR-2 - 100 Capsules, 450 mg each X $29.95 =
Bowel Cleanse BWL-3 - 100 Capsules, 380 mg each X $27.00 =
Candcell-PC Antifungal - 100 Capsules, 450 mg each X $28.95 =
Cerebral DHA - 90 Capsules, 500 mg each X $26.95 =
Clear-Mind® - 60 Capsules, 275 mg each X $39.95 =
EZ-Energy® Athletic Formula - 60 Capsules, 600 mg each X $38.95 =
Four-in-One Weight Control Formula X $19.50 =
GlucoRite™ - 90 capsules 710 mg X $54.95 =
Liver Cleanse LVR-C-1 - 100 Capsules, 450 mg each X $26.00 =
Nu-Flex® - 90 Capsules, 775 mg each X $39.95 =
Pet Well® X $19.95 =
Plant Cell Vitamin C - 120 Capsules, 500 mg each X $19.50 =
PS Plus X $41.95 =
Rosavin™ - 60 Capsules, 100 mg each X $20.95 =
Rosavin Plus® - 90 Capsules, 150 mg each X $27.95 =
S.R.C.™ - 90 capsules, 150 mg each X $27.95 =
Super EFA with Omega 3-6-9 X $29.95 =
The Original Olive Leaf Extract® - 60 Capsules, 525 mg each X $24.95 =
The Original Olive Leaf Extract® - 90 Capsules, 525 mg each X $32.95 =
T.O.O.L.E. for Kids - 100 Capsules, 100 mg each X $19.95 =
Viban™ - 30 Capsules, 750 mg each X $20.95 =
Xtreme Tasteez™ 3 flavors, 30 Packs, 5 grams each X $19.95 =
Product SUBTOTAL:
Preferred Customer SAVINGS:
MONTHLY TOTAL: