| NAME: | |
| ADDRESS: | |
| CITY | |
| STATE | |
| ZIP CODE | |
| PHONE: | |
| ORDER DATE: |
| PRODUCT: | Book - "The Rebirth of Our Republic" |
| PRICE PER BOOK: | $12.00 per book |
| QUANTITY: | |
| SUB TOTAL: | |
| SHIPPING 1st BOOK: | $4.00 |
| SHIPPING ADD'L BOOKS |
|
| SALES TAX (CA 7.25%, CT 6%) | |
| GRAND TOTAL: |
I choose to order by:
Check or money order
Credit Card # ____________________________________Exp. ___/ ___
_____________________________
Signature of Authorized User_________________
Date
If shipping address is different from above address, please provide the shipping address below.