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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____CONCENTRATED Minerals Liquid 4oz..1/$17.50 12/$180.00.$_________
____CONCENTRATED Minerals Liquid 4oz Value 4 Pak.4/$65.00.$_________
____CONCENTRATED Minerals Liquid 4oz Value 6 Pak.4/$95.00.$_________
____ORIGINAL Minerals Liquid 32oz.....1/$18.50 12/$195.00.$_________
____ORIGINAL Minerals Liquid 32oz Value 4 Pak.. 4/ $70.00.$_________
____ORIGINAL Minerals Liquid 32oz Value 6 Pak.. 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/$140.00.$_________
____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 7.75% 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 - 4oz. Liquid Product    $5.50  $5.50  $8.00  $8.00 $12.00 $14.00
All -16oz. Liquid Product    $9.00  $9.50 $10.00 $10.50 $13.00 $19.00
All -32oz. Liquid Product   $11.00 $12.00 $13.50 $14.00 $18.00 $28.00
All -30-90 count Capsules    $5.50  $5.50  $5.50  $8.00 $10.00 $12.50
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Payment can be credit card, check, or money order (no cash please)
(note: credit card orders can only be sent to cardholder's address)

Visa/M/C/Amex Card #________________________________Exp. Date________

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