Fax/Mail Order Form

RITA M. STAMP
          238 Mary Street
          Thorold, Ontario
          Canada  L2V 1J8

Printable Fax / Pre-Order Mail Form

Please note that "R.E.A.L." is now available and may be purchased directly (autographed) from me at: (905) 227-6378, or ordered on-line at Chapters-Indigo. This form is available if you would like to order your copy via fax to: (905) 227-2656.

Name: (or Company) _______________________________ Date: ____________________________

Mailing Address: _____________________________________________________________________

City: _________________________________________ Province / State _______________________

Postal / Zip Code: _______________________________ Country ___________________________

Phone: __________________ Fax: _______________ E-mail: ____________________________

Order placed by Fax, Phone, E-mail, Regular Mail (please specify) ______________________________

Payment method:

VISA # (or) Master Card (circle one) ______________________________ Expiry Date ______________

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Quantity Description of item Unit Cost Total Cost

______ ________________________________ ____________ _____________

______ ________________________________ ____________ _____________

______ ________________________________ ____________ _____________

Subtotal _______________

Shipping Charges _______________

Taxable Subtotal _______________

THANK YOU! GST _______________

TOTAL COST: $ ___________