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Description / Title of Book or Magazine Name and Date(s)
Total Cost
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Billing Address:
If paying by credit card, must match name on card.
Title:
Mr.
Mrs.
Miss.
Ms.
Dr.
First Name:
Last Name:
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Country:
[Country Code List]
Email:
Day Telephone:
Night Telephone:
Fax:
Shipping Address:
The Shipping Address is the same as the Billing Address :
Title:
Mr.
Mrs.
Miss.
Ms.
Dr.
First Name:
Last Name:
Company:
Street:
City:
State:
Please use the state/provincial abbreviations provided by your postal system.
Zip/Postal Code:
If shipping to US address, please include your Zip +4. If you do not know add 0000.
Country:
[Country Code List]
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12 (December)
Year:
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2023
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