Please print out this form to order.

SOLD TO:

NAME______________________________________

ADDRESS___________________________________

CITY_______________________________________

STATE____________________ZIP_______________

PHONE_____________________________________

EMAIL_____________________________________

SHIP TO (if different):

NAME______________________________________

ADDRESS___________________________________

CITY_______________________________________

STATE____________________ZIP_______________

PHONE_____________________________________

EMAIL_____________________________________

QTY

ITEM

ITEM
PRICE

TOTAL
AMOUNT

MIDA-PLEX Glucosamine Complex
(120 wafers per bottle. 30 day supply.)

$39.95
Free Shipping!

MIDA-GOLD Anti-Inflammatory
(120 wafers per bottle. 30 day supply.)

$39.95
Free Shipping!

MIDA-BLUE Hyaluronic Acid
(30 wafers per bottle. 30 day supply.)

$39.95
Free Shipping!

CASE of 12 bottles
(Only $28.00 per bottle)

$336.00 per case
Free shipping!

SALES TAX
8.25% for NY

GRAND
TOTAL:

METHOD OF PAYMENT
CREDIT CARD (Circle One):
MC • VISA • AMEX
Account Number:

_ _ _ _ / _ _ _ _ / _ _ _ _ / _ _ _ _

Expiration Date: _______________

Signature____________________________________
 

______CHECK OR MONEY ORDER
Please make payable to: Mida Enterprises

Please fax this order to:
631-472-8075

or

Mail to:
MIDA Enterprises
P.O. Box 537
Holbrook, NY 11741

Questions?
1-877-422-0222