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| JCNTV CUSTOMIZED VITAMINS ORDER FORM |
| SEND ME my PrivaTest Kit, CONDUCT MY Lab test, MAKE the specific nutritional supplements I need to restore my body’s natural ability to detoxify itself, handle challenges to my antioxidant systems and balance my immune, Vascular and Nervous systems. |
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SHIP my PrivaTest Results Report and my first monthly supply of
Custom Supplements. Please deduct $79.95 from my credit card for the PrivaTest with PrivaTest Kit. |
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After that, please deduct from my credit card $55.95 plus shipping, handling and local taxes (if any) for each monthly supply when you auto-ship my Custom Supplements to me. |
| PLEASE PRINT CLEARLY |
__________________________________________________________________________________________ Last name First name M Date |
| ___________________________________________________________________________________________ Address City/State Zip Code |
| (_________)__________________________ Phone Number |
| ___________________________________________________________________________________ Credit Card Number Expires |
| _____________________________________________________________________ Primary Cardholder’s name |
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______________________________________ |
| Send this order form via fax at (619) 296-4532 Or E-mail info @JCNTV.com |
| BACK to vitamins. |