Pamphlet Order Form
“What You Should Know About Prostate Cancer”
Pamphlet Order Form Print this page then return by mail or fax to 310-743-2113
Name: _______________________________________________________
Organization: __________________________________________________
Address: _____________________________________________________
City: _________________________________________________________
State: _______________________ Zip: _____________________
Day Phone: (_____) ________________
Email: _____________________________________________________
Pamphlets cost 10¢ each, and there is a minimum order of 100
Please indicate the number of pamphlets you would like to order:
Number of copies: _____ x 10¢ = $ __________ Total Cost
Make check payable to: Prostate Cancer Research Institute
Or pay by credit card: Visa ___ MC ___ Am Ex ___ Discover ___
Card #: ___________________________________ Exp. Date: ____/____
Name on card: _________________________________________________
Signature: _____________________________________________________
