| Quantity | Price | Subtotal | |
| Self-Care Manual | _________ | _________ | _________ |
| Video Tape | _________ | _________ | _________ |
| Floppy Disk | _________ | _________ | _________ |
| Order Total | _________ | ||
| Tax (8%) | _________ | ||
| Shipping |    $5.00      | ||
| Total | _________ |
| Name_____________________________________ | |
| Address___________________________________ | |
| __________________________________________ | |
| City, State Zip_______________________________ | |
| Phone_____________________________________ |
| Method of Payment | |
| Check                     | |
| Visa                        | |
| MasterCard             |   Credit Card #__________________________Exp. Date_____________ |
| American Express     |   Signature______________________________________ |