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Saving Lives Video Order Form
For orders by check: Please print and complete the following form below and mail it with a check for $10 to:
Saving Lives Video Order
1400 Eye Street, NW
Suite 1200
Washington, DC 20005
For orders by credit card: Please print and complete the form below and mail to the address above or fax to 202.296.5427, Attn: Saving Live Video Order
| Name: | ___________________________________________ |
| Organization: | ___________________________________________ |
| Street Address: | ___________________________________________ |
| City: | ____________________ | State: | _____ | Zip: | __________ |
| Phone: | ____________________ |
| Fax: | ____________________ |
| Email: | ____________________ |
| Intended Use: | ____________________ |
Cost per package (includes shipping) .......... $10.00
(Each package contains one video and 10 brochures)
| Quantity: | __________ |
| Visa or Mastercard Number: | ___________________________________________ |
| Expiration Date: | __________ |
| Signature: | ___________________________________________ |
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