Contact Information
Name _______________________________________________________________________________
Address ____________________________________ City, State, ZIP ____________________________
Phone (______) ______________________________ Email (Optional) ___________________________
Shipping Address (if different)
Name _______________________________________________________________________________
Address ____________________________________ City, State, ZIP ____________________________
If paying by check, make check payable to Paidia Press.
If paying by credit card, please complete the following information:
Type: ___VISA ___ MasterCard ___ Discover Credit Card # _________________ Exp. _______
Number of Books ______ x $25.00 (including tax and shipping) per book = Total __________________
Signature ___________________________________ Date ____________________________________ |