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: $ ___________