Ecstatic States Fax Order Form
(within Australia)

Please fill this page out, and then print it and
Fax to (02) 9371 7099

or make cheque or money order in the name of

Wiseone Edutainment P/L

and

Mail To

P.O. Box 25, Rose Bay,
NSW, 2029, Australia

First Name:
  *
Last Name:
  *
Street Address:
  *
Address (cont):
City:
 *
State:
  *
Postal/Zip:
  *
Contact Phone:
 * (one phone required)
Home Phone:
Fax:
E-mail:
 *

Quantity
Please send me:  * copy of the Ecstatic States DVD with Ram Dass .

Useage & Payment
I intend to use this DVD;

for my private or personal use only
(investment of $AUS29.95 inc GST + $AUS5.00 postage & packaging)

within my workplace, institution or organization*
(investment of $AUS79.95 inc GST + $AUS5.00 postage & packaging)


Media Type
I would prefer to receive a

DVD

VHS Videotape


Television Format
Please choose your country's format

 format for for USA Canada and Mexico (NTSC)

format for Australia, UK and Europe (PAL)


Payment method
I would like to make my payment using

Visa American Express
Master Card

Bank Card
Diners Club    

Cardholder Name:
  *
Card Number:
  *
Expiry Date:
 * (format mm/yy)

 

Comments


* = required fields

* The "within my workplace, institution or organization" purchase allows the series
to be used for teaching / training purposes within the institution making the
purchase and for lending to individuals who are part of that institution.


P.O. Box 25, Rose Bay, NSW, 2029, Australia
Ph: +61 2 9371-3933 Fax: +61 2 9371-7099
Email: jcoroneos@bigpond.com