GALEN PRESS Secure Online Order Form

Secure Online Order Form


Ordered By:
E-MAIL:
FIRST NAME:
LAST NAME:
ADDRESS:
ADDRESS Line 2:
CITY:
STATE/PROVINCE:
ZIP/POSTAL CODE:
COUNTRY:
PHONE: FAX:
SEND SHIPMENT TO: (If same as above, please leave blank)
E-MAIL:
FIRST NAME:
LAST NAME:
ADDRESS:
ADDRESS Line 2:
CITY:
STATE/PROVINCE:
ZIP/POSTAL CODE:
COUNTRY:
PHONE: FAX:
Discount Code Or Additional Information:
YOUR ORDER
Quantity	Catalog #	Title or Description	Price Each	Total Price






Subtotal
Sales Tax (AZ residents add 8.1%)
Regular Mail (7-12 days): $3.99 for each item. Priority Mail (2-3 days): $6.99 for each item.			Shipping/Handling:
Total:

Credit Card Information:
VISA Mastercard Please choose one!
Card Number:
Card Verification Number (what is this?)
Expiration Date:
Name On Card:
ZIP/POSTAL CODE ON CARD BILLING ADDRESS:
Shipping & Handling charges are for U.S. destination, and may vary for multi-item orders. Please Fax or Call for exact charges on large orders, United Parcel, overnight delivery, and delivery outside the U.S. Quantity discounts available on selected titles. Prices subject to change without notice.
Return Policy Returns will be accepted within thirty days for items other than software if the items and the invoice are returned to us (at your expense) in salable condition. We will refund only the purchase price of the item(s) returned; we cannot refund shipping or handling charges. Defective software will be replaced if returned to us.