Please provide the following contact information:

Name
Title
Organization
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Work Phone
FAX
E-mail

Please provide the following ordering information:

Publication Order Form
QTY	Description	Cost	Total
0 1 2 3 4 5 6 7 8 9 10	Sets of Her Shoes are brown & jumping the Gap	$15 ea.	$0 $15 $30 $45 $60 $75 $90 $105 $120 135 $150 $165 $180
0 1 2 3 4 5 6 7 8 9 10	The community involvement news	$12 ea.	$0 $12 $24 $36 $48 $60 $72 $84 $96 $108 $120
	Sub-Total
	Shipping & Handling@$3.50 for first set (add $3.00 ea. additional set)
	*All order include taxes
	Total (to be invoiced)

	BILLING
Purchase order #
Account name

	SHIPPING (if different from above)
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country