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
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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: