COPE Logo Center for Psychological Effectiveness
Fax / Mail Order Form

Please use the Print button in your browser to print this form. Fill out the printed form, and then send or fax it with your payment to:

Fax to:

954-489-9779

Mail to:

COPE
6950 Cypress Road - Unit 103-A
Plantation FL. 33317 
Fax: 954-489-9779

Name (Please Print)

 

Address (Line 1)

 

 Address (Line 2)

 

City

  
State  

Zip / Postal Code

  

Phone #

 

Fax #

 

E-Mail Address

 

Alternate E-Mail

 

Item Description 

Price Each

Quantity

Extended Price

Power of Wisdom: A Path for Women Book

$10.95 (US)

 

 

Addition Books for Holiday Gifts

$8.95 (US)

  

 
Shipping / Handling (First Book)
 4.95
Additional Shipping: add $1.00 per each additional book
  

Total Amount Enclosed

 

 
Payment Method (circle):  CASH   /   CHECK   /   MONEY ORDER   / 
                                      VISA   /   MC   /   DISCOVER   /   AMERICAN EXPRESS
 

** Please make check or money order payable to "COPE"
** All checks or money orders in US Funds only

 

Please add the following information for credit card orders:

Card# _________________________________    Exp. Date: ____ / ____

EXACT Name on Card: _________________________________________

Signature ____________________________________________________