Ecstatic States Fax Order Form
(outside Australia)

Please fill this page out, and then print it and
Fax to +61 2 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:
  *
Country:
 *
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 $US25.00 + $US5.00 postage & packaging)

within my workplace, institution or organization*
(investment of $US65.95 + $US5.00 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 UK, Europe and New Zealand (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.


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