Print out this form and complete it and send it along with cashier's check or money order. (NOTE: Only
payment from banks in the United States accepted.)
Your Name: ______________________________________________________
Your Address: ____________________________________________________
Your City, Stae, Zip: _______________________________________________
eMail address: ____________________________________________________
phone number: ___________________________________________________
Name of who items should be sent to: (If other than you.)
__________________________________________________________________
Address of who items should be sent to: (If other than you.)
__________________________________________________________________
City, State, Zip: ___________________________________________________
Items to Order and Pricing Amount
Due
Book (enter quantity) _____ @ $9.00 ea
___________
Toilet Adapter Seat (enter quantity) ______@ $11.00 ea ____________
Signed By Author (enter quantity of books) _____ @ 3.00 ____________
Gift Wrapping (enter # packages) ____ @ $10 ea
____________
Include A Card @ $ 5.00 ____________
Circle Type Of Card: Congratulations for becoming new partents
Congratulations
for the birth of a girl
Congratulations for the birth of a boy
Congratulations
for becoming pregnant
Have A Message Written In Book @ $5.00
_____________
Enter message up to 30 words. Be sure to enter who it is to and from:
To: __________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Closing Before Name (Love, Best Wishes,etc. ) _______________________
From: ______________________________________
Add Shipping and Handling Charges:
___________
Shipping and Handling: $5.00 if total is under $10.00
$8.00 if total is between $10.00 and $49.99
$15.00 if total is between $50.00 and $99.99
$25.00 if total is between $100 and $199.99
$40.00 if total is over $200
Add Tax if in Missouri
___________
Total Enclosed
___________
