Video Order Form
Please print out this order form, complete it and send it to the following
address:
Los Altos Rotary AIDS Project
P.O.Box 794
Los
Altos, CA 94023
or telephone us at 415-688-6164
Please print out this order form, complete it and send it to the following
address:
Los Altos Rotary AIDS Project
P.O.Box 794
Los
Altos, CA 94023
or telephone us at 415-688-6164
| YES! I would like to make an order: | |
| Please write your desired quantities in the blanks: | _____Los Altos Story ($25.00-US Dollars) |
| _____Rotary AIDS Project "Making A Difference" ($25.00 -US Dollars) | |
| _____AIDS: The Community Challenge-A Symposium ($25.00-US Dollars) | |
| Total # of Videos___________________ | |
| Total amount due:$__________________ | |
| Please add $10 for shipping/handling for any orders outside of Canada or the U.S. | |
| The Los Story is available
in the following subtitles. Please circle one:
English - French - German - Italian - Japanese - Portuguese - Spanish | |
|
| |
| Method of Payment: (circle one) | |
| Check or Money order | Cardholder Name:________________________ |
| VISA | Card # _______-_______-_______-______ |
| MasterCard | Exp. Date ________________ |
| Cardholder Signature
_____________________________ | |
|
| |
| Mailing Information: (please print clearly) | |
| Name:___________________________________________________ | |
| Street Address: _________________________________________________________ | |
| City:_____________________________________________________ | |
| Province:_________________________________________________ | |
| State:_____________________________________________________ | |
| Country:__________________________________________________ | |
| Postcode:_________________________________________________ | |
| Rotary AIDS Project Home Page |