PLEASE PRINT THIS ORDER FORM AND MAIL TO:
  BioNeurix Order Department
  PO Box 594
  Orange, CT 06477
  
       ***** Please PRINT LEGIBLY *****
(To ensure that your order is sent to the correct
address, write all information slowly and clearly.)

NAME______________________________________

SHIP-TO ADDRESS___________________________

__________________________________________

CITY__________________STATE____ZIP________

EMAIL_____________________________________

PHONE______-______-________

COMMENTS__________________________________

__________________________________________

__________________________________________

                        QTY     PRICE   TOTAL

MELLODYN  1 bottle      ___  x  24.95 = _____ 	

MELLODYN  3 bottles     ___  x  49.95 = _____

MELLODYN  6 bottles     ___  x  89.95 = _____

OTHER________________   ___  x ______ = _____

SHIPPING ($8 US, $25 Can, $55 Global) = __.00
                                            
                                        =====
                                   	
                               TOTAL: _______
                               
ALL PRICES IN U.S. DOLLARS.

Select and enclose payment method:

___Check payable to "BioNeurix Corporation"

___Money Order payable to "BioNeurix Corporation"

___Visa      ___MasterCard      ___AmericanExpress

CARD NUMBER______-______-______-______EXP____/____

NAME ON CARD______________________________________

BILLING ADDRESS___________________________________
               (if different from Ship-To Address)

THANK YOU for your order.
Please allow two weeks for delivery.