The Pathwork

QTY	DESCRIPTION	Amount
	Subtotal
	Shipping/Handling
	If N Y S resident, check here Sales Tax (N Y S 7.25%)
	Total billed to credit card

	BILLING
Credit card	VISA MasterCard American Express Diner's Club Discover
Cardholder name
Card number
Expiration date

	BILLING ADDRESS
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Work Phone
Home Phone
FAX
Email Address
	SHIPPING (if different from above) (UPS will not deliver to a P.O. Box)
Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal code
Country