Order Form

Fixing Our Broken Health Care System by: Charles Scott

Print out this order form, and send it along with your check to:
Mountain States Lithographing 133 S. McKinley St. Casper, WY 82601
or FAX to: 307-237-9521

Name: ________________________________________________________

Address: ______________________________________________________

City: ____________________ State: ____________ Zip: _______________

Phone number:____________________(You must include your phone number!)

E-Mail:_______________________________________________________

Ship Order To: If same as above, leave blank

Name: ________________________________________________________

Address: ______________________________________________________

City: ____________________ State: ____________ Zip: _______________

Product Order
Description	Quantity	Price	Total
Fixing Our Broken Health Care System	_______________	$19.95 U.S.	_______________

Subtotal of Order	$_________________________
Sales Tax 5% (if in WY)	$_________________________
Shipping $3.50 on the first book	$_________________________
Shipping $1.50 for each additional book	$_________________________
TOTAL	$_________________________

Please, call for shipping charges on multiple orders (800) 584-9340

With Order: I've enclosed $__________ as payment in full. (Make check payable to Mountain States Litho.)
Or, In Full By Credit Card: Charge my order to my credit card indicated below:
Credit Card Information: Visa, MasterCard, Discover

Card Number _________________________________________ Expires __________

Name on Card _________________________ Signature _________________________