<<<<<<<Please
print this page to order>>>>>>>
"My Personal Health Record Diary"
Price per Book: $14.95 (Canadian) or $12.95 (US)
ORDER FORM |
|
| Number of Books_____ @________
= $________ |
|
| ADD: Shipping and
Handling................$________ (Shipping = Canadian $2.00 / US $2.40) |
|
| SUBTOTAL............................................$________ | |
| G.S.T. (7% Canadian Orders Only)......$________ | |
| TOTAL AMOUNT ENCLOSED..........$________ | |
|
|
|
NAME:________________________________________________ |
|
STREET:______________________________________________ |
|
CITY/TOWN:___________________________________________ |
|
PROVINCE/STATE:______________________________________________________ |
|
COUNTRY:____________________________________________ |
|
POSTAL CODE/ZIP:_____________________________________________________ |
|
| TELEPHONE: ( ) ______________FAX ( )___________ | |
| E-mail____________________________________ | |
|
Please make your cheque or money order payable to: (Please allow up to 3 weeks for delivery) |
|