SHIPPING & MAILING COST
 

	BILLING ADDRESS
First name
Last name
Middle initial
Title
Organization
Work Phone
Home Phone
FAX
E-mail
URL
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Credit card	VISA MasterCard American Express Diner's Club Discover
Cardholder name
Card number
Expiration date Payment by Check	Print this orderform and mail it together with your check to: Disciples of Mercy Foundaion P.O. Box 4074 Deerfield Beach, FL 33442-4074

	SHIPPING ADDRESS if different from Billing
First name
Last name
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Enter the date of  your purchase: -- mm/dd/yy   We are happy to answer you questions and/or comments. Please write them down for us in the box below: