RETAIL ORDER FORM

If you are placing a retail order,

please print this page out and return with your check to:

Gary Porell, 600 Franklin Rd, Fitchburg, MA. 01420

If you do not own a printer,

please e-mail your order and forward your payment.

Product Description	Quantity	Retail Cost
Example: Barleygreen 7 oz with kelp	1	$ 35.50
Item 1:	:	$
Item 2:	:	$
Item 3:	:	$
Item 4:	:	$
Item 5:	:	$
If order is under $50 add $5 shipping in US	:	$
:	TOTAL	$

SHIPPING INFORMATION

Name:

Street:

City:

State:

Zip:

Telephone: