DSI ON CD Mail-In Order Form
Print Out - Fill Out - Mail In (US Funds Only)

• Send me ______ DSI Vol. dual disc set(s) @ $25.00 ea.
• $ ____________ Total Cost of Sets Ordered
• $ ____________ Shipping & Handling (FREE- US) -- (Canada $4.75) -- (Europe-UK $6.95)

Total: ________________

______________________________________________

Name: ___________________________________________________________

Company: ________________________________________________________

Shipping Address: __________________________________________________

City: _____________________________________________________________

State: _______________________________________ Zip Code: _____________

Mailing Address (if different): _________________________________________

Phone (Days): ____________________ Phone (Eves): ______________________

e-mail Address: ___________________________________________________

Special Instructions:________________________________________________

Select Payment Type: (include payment with form)

Check Payment Type: _____Cashiers _____ Money Order _____ Certified Check
_____ Personal Check
Check Number: __________ (personal checks need to clear our bank before order is shipped)

Make checks payable to: Left Coast Web Grapics

Mail Order Form To:
Left Coast Web Graphics
210 SW Pine St.
Grants Pass, OR 97526