T.J.CLARK MINERALS - ORDER FORM 
T.J. Clark Minerals - http://www.tjclark.net
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Your Name__________________________________________________________ 
Address________________________________________ (business/residence) 
City_______________________________________________________________ 
State___________________________  Postal Zip_______ Country________
Home Phone______________________  Business Phone___________________
e-mail address:____________________________________________________ 
Shipping Address (no P.O.Boxes allowed if ship total is over $5.00)
Address________________________________________ (business/residence) 
City_______________________________________________________________ 
State___________________________  Postal Zip_______ Country________
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I want to place a Regular Discounted Order for the following..... 
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____4oz. CONCENTRATED Liquid Minerals.1/$17.50 12/$180.00.$_________
____Value 4 Pak.4oz.CONCENTRATED Liquid Minerals 4/$65.00.$_________
____Value 6 Pak.4oz.CONCENTRATED Liquid Minerals 4/$95.00.$_________
____32oz ORIGINAL Liquid Minerals.....1/$18.50 12/$195.00.$_________
____Value 4 Pak.32oz ORIGINAL Liquid Minerals...4/ $70.00.$_________
____Value 6 Pak.32oz ORIGINAL Liquid Minerals...6/$102.00.$_________
____ORIGINAL Minerals 60 capsules.....1/$18.50 12/$195.00.$_________
____CHROMIUM Picolinate Liquid 16oz...1/$18.50 12/$195.00.$_________
____MSM Advanced Formula Liquid 32oz..1/$13.50 12/$150.00.$_________
____Multi-Vitamins 30 capsules........1/$12.50 12/$140.00.$_________
____Liquid Multi-Vitamins 8oz.........1/$12.50 12/$140.00.$_________
____Calcium/Magnesium 60 capsules.....1/$12.50 12/$140.00.$_________
____Glucosamine/Condroitin 60caps.....1/$17.00 12/$185.00.$_________
                                        My Sub-Total is $___________
             if delivered in Calif. add 8.75% sales tax  $__________
              refer to chart below to add Shipping Costs $__________
In freezing weather areas add "Signature Required" $3.00 $__________
                                            My TOTAL is $___________
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U.S. Shipping & Handling* - qty.->1      2     3      4      6       12    
All -  30-90 count Capsules    $5.50  $5.50  $5.50  $9.00  $10.00  $12.50
All -   4oz. Liquid Product    $5.50  $5.50  $9.00  $9.00  $12.00  $14.00
All -   8oz. Liquid Product    $5.50  $9.00 $12.00 $12.00  $14.00  $15.00
All -  16oz. Liquid Product    $9.00 $12.00 $13.00 $14.00  $15.00  $21.00
All -  32oz. Liquid Product   $12.00 $13.00 $14.00 $15.00  $19.00  $28.00
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Visa/M/C/Amex Card #________________________________Exp. Date________

Card CID#______(these are the last 3#'s on back, or Amex 4#'s on front)

Signature____________________________________________________________
	 Yes, I hereby authorize this charge

Mail-In or FAX to: Rodrigue & Sons Co. - Int'l TJClark Distributor
116 E. College Ave. Suite 170  Lompoc, CA 93436-5335 USA.
Toll Free 24 hr. Voice Mail Order Desk : 800 913-4-TJC (800-913-4852)
FAX to: 805 737-9846 or Voice: 805 737-9845 between 10AM-5PM PST