ORDER FORM

P.O. Box 2768

Madison, MS 39110

Address_______________________________________

________________________________________

FOR OFFICE USE

DATE	REQUISITIONER	SHIPPED VIA		TERMS

QTY	UNIT	DESCRIPTION		UNIT PRICE	TOTAL
		Hardback ( Mississippi ’s Uncovered Glory)		$26.50


COMMENTS: Shipping & Handling is $3.00 per book Mail along with your check or money order to address above:			SUBTOTAL
			SALES TAX		No Tax
			SHIPPING & HANDLING (Add)
			OTHER		0
			TOTAL

I hereby authorize the charge of $___________ to

› Visa › MasterCard › AMEX › Diners

Card Number: ______________________ Expiration Date: ____________

Name as it appears on card:

_______________________

Billing Address for Credit

Card:__________________________________ Zip Code:_______________

Signature:

_____________________________________ Date: ________________

Phone No:_________________________________

E-mail: __________________________________

Signature

Date