Living With Fibromyalgia
ORDER FORM
– Please print out and complete this form to place your order –
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Bulk orders, please do NOT use this form.
Contact us for special pricing and shipping information.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

______ Copies of DVD

______ Exhibition DVD

  

x  $29.95

x  $149.95

  

= $ ____________

= $ ____________
     
SUBTOTAL
  

= $ ____________

Applicable Sales Tax
California residents add 8.5%

  

 

  
= $ ____________

$1 Unit Shipping & Handling

  

x  $5.95

  

= $ ____________
 

$________ Additional Units S & H

x  $1.50
    each

= $ ____________

$

 

 

     
GRAND TOTAL
  

= $ ____________
 

SHIP ORDER TO:
(please print in block letters)

/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/
First Name

/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/
Last Name

/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/
Company or Organization

/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/
Street

/___/___/___/___/___/___/___/___/___/
Apartment or Suite Number

/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/
City

/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/
State

/___/___/___/___/___/
Zip Code / Postal Code

/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/
Country

/___/___/___/ – /___/___/___/ – /___/___/___/___/
Phone Number

_____________________________________________________
Email Address
 
MAIL ORDER FORM ALONG WITH
CHECK OR MONEY ORDER
MADE OUT TO:		 Trillusion Media, Inc
240 9th Ave.
San Francisco, CA 94118

– Orders will be shipped in 5-7 business days once payment is received. –
– $25 Returned Check Fee –
Questions?
Phone: 800-724-9948
Email: info@trillusionmedia.com