Dr. Happy Tooth's Comic Book Order Form

CHILDREN'S DENTAL HEALTH PACKAGE ORDER FORM FOR

"DR. HAPPY TOOTH GETS DOWN IN THE MOUTH" COMIC BOOK

Email Address
Name
Address
City	State	Zip Code
Phone	Fax

Please input how many of each you would like to order

Classroom Package A	@ $79.95 =	$
Classroom Package B	@ $179.95 =	$
Health Fair Package	@ $1,995.00 =	$
Individual Comic Books	@ $1.00 =	$

Subtotal		$
Please add 8.5% sales tax		$
Grand Total		$

IMPORTANT! THIS INFORMATION IS NOT BEING SUBMITTED THROUGH A SECURE SERVER...

Please choose the payment option you desire

Please print out a copy of this completed order form
Mail with check to: 2930 Martin Luther King Jr. Way, Berkeley, CA 94703

Please complete the following section
Click the submit button on the bottom OR
If you are not comfortable with the non-secure server

Please print out a copy of this completed order form
Mail to: 2930 Martin Luther King Jr. Way, Berkeley, CA 94703

Credit Card Information

Name (Print name as shown on card)
Account Number		Exp. Date (mm/dd/yy) or (mm/yy)
Signature		Date (mm/dd/yy)

BY FILLING IN THE SIGNATURE AND DATE FIELD, IT ACTS THE SAME AS A SIGNATURE. PLEASE DON'T FORGET TO FILL IN THESE FIELDS PRIOR TO SENDING.

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