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Your first copy is free. Each additional copy will be $5.
Please print this page, complete, and fax or mail to Janice Marie Ferguson. (jferguson@cord.org e-mail or 254-800-518-1410 ext. 253 phone)
Fax:
Mail:
Name:_________________________________________________________________
Organization:____________________________________________________________
Address:_______________________________________________________________
City:____________________ State: __________ Zip:___________________________
Phone:________________________________________________________________
E-mail:________________________________________________________________
Quantity of DVDs:________________
Total:$__________
Method of Payment:
___CHECK #___________________
___PURCHASE ORDER #___________________
___CREDIT CARD: Circle one VISA MASTERCARD AMERICAN EXPRESS
CARD #_______________________________________________________________
Expiration:___________ Signature: _________________________________________
Billing Organization:______________________________________________________
Billing Address:_________________________________________________________
City:___________________ State:____________ Zip: _________________________
Billing Phone:___________________________________________________________
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© 2012 CORD. All Rights Reserved. |
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