Auto Ship

NCP Miracle II

1247 Brightleaf Blvd. #10 Smithfield, NC 27577

Phone (919) 284-6002 or (919) 284-0598 Fax (919) 284-4197

AUTO SHIP REQUEST FORM

The company will begin shipments on the 20th of each month. In order to cancel or change your auto ship for the month, you must notify us at least two working days prior to the 20th. If you place an order in addition to the monthly auto ship order, you will receive both orders unless you ask us to skip your auto ship for the month. Please complete, sign and return this form (either by fax or mail) to our office as authorization for this request.

Item

Product Name

Quantity

Wholesale Price

Total

01

Moisturizing Soap (22 oz.)

#

16.00

$

02

Neutralizer (22 oz.)

#

16.00

$

03

Regular Soap (22 oz.)

#

16.00

$

04

Skin Moisturizer (8 oz.)

#

16.00

$

05

Neutralizer Gel (8 oz.)

#

16.00

$

19

15% Neutralizer (22 oz.)

#

32.00

$

06

Laundry Ball

#

45.00

$

07

Deodorant Stone

#

12.00

$

08

Regular Soap (Gallon)

#

67.00

$

09

Neutralizer (Gallon)

#

67.00

$

10

Skin Moisturizer (Gallon)

#

180.00

$

11

Neutralizer Gel (Gallon)

#

180.00

$

12

Moisturizing Soap (Gallon)

#

67.00

$

17

10% Neutralizer (Gallon)

#

90.00

$

18

15% Neutralizer (Gallon)

#

180.00

$

^{Total of Order . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . __________}

Add S&H 9% of Wholesale (Minimum $6.00) . . . . . . __________

Total Amount Paid . . . . . . . . . . . . . . . . . . . . . . . . . . . __________

Last Name ___________________________________________

First Name ___________________________________ MI _____

ID Number ________________

Signature ______________________________ Date _________

Shipping Address _____________________________________

City __________________________State _______ Zip ______

Credit Card (MC/Visa)

Name on credit card: __________________________________

CC# ________________________ Expiration ______________

Day Phone # if company has questions about this order:______________________________________________

SPONSOR: Rep. i.d.#1300 / miracle2.org