Please
print (in portrait mode),
make appropriate entries,
and...
Fax to: 815.301.9143
or
SnailMail to: Dr. PM
10534 NE 121 Hwy
Cameron, MO 64429
| Personal/Organizational Information |
SKU# (on description page) | Order Quantity |
Price
Each |
Price Extended | |
| Name: |
_________________________ | ___________ | ______ | $ | $ |
| Organi-zation | _________________________ | ___________ | ______ | $ | $ |
| Email: | _________________________ | ___________ | ______ | $ | $ |
| Address: | _________________________ | ___________ | ______ | $ | $ |
| City: | _________________________ | ___________ | ______ | $ | $ |
| State: | _________________________ | ___________ | ______ | $ | $ |
| Zip: | _________________________ | ___________ | ______ | $ | $ |
| Country: | _________________________ | ___________ | ______ | $ | $ |
| Phone: | _________________________ | ___________ | ______ | $ | $ |
|
Order
|
SubTotal—
|
$ | |||
| eBook Bonus: |
Achieving Successful Sexuality | ___________ |
1
|
FREE | FREE |
|
OR
|
|||||
| Consulting Bonus: |
10
additional minutes of FREE |
______ minutes |
FREE | FREE | |
| Sales Tax: | (ONLY applicable in Missouri) | @6.85% (Missouri ONLY) |
$______ | ||
| Shipping: | $5.95 per volume in USA; 8:95 USD per volume non-US |
Shipper |
Weight
______# |
$______ |
|
|
Order
|
Total—
|
$______ |
Please enclose payment for Order Total made out to Dr. Porter-Murdock