Please print and complete this form,
then fax or mail it to Cheltenham Press |
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| Cheltenham Press |
| PO Box 1605 |
| Portland, OR 97201 |
| Fax (503) 245-3909 |
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| Purchaser information |
(this must match the name and address for the payment information): |
| Name______________________________________________________________ |
Address____________________________________________________________ |
City_____________________________ |
State ____________________________ |
Zip__________-______ |
Phone (___) ____-_______ |
Email________________________________________________________________ |
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| Shipping information: Check
if same as Purchaser |
Name______________________________________________________________ |
Address____________________________________________________________ |
City_____________________________ |
State ___________________________ |
Zip __________-______ |
Phone (___) ____-_______ |
Email________________________________________________________________ |
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| Item |
Quantity |
Price |
Total |
| Coping in New Territory |
________EA |
$13.95 |
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| Shipping |
________EA |
$ 2.00 |
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Total |
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Terms: _____ Check _____ VISA _____ MC |
| Card Number |
________________________________________ |
| Exp (MM/YY) |
_______/_______ |
| Suzanne, please autograph this book for |
_______________________________ |
This order is correct in all details and I assume responsibility for payment. |
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Date: |
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| Buyer's Signature |
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