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For our Records:

First name
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Last name
Phone #
Email
Age
Sex	Male Female

Please provide the following ordering information:

Number of Mom and Pop Stores Books	@ $39.95 each (U.S. only)
Shipping & Handling	@ $5.00 each (U.S. only)
	Total
	Iowa residents add 6% sales tax

Inquire about Dealer Quantity Discounts

Method Of Payment: Please feel free to print this form and mail it, along with check or money order to: Pennyfield's Publishing P.O. Box 1355 Waterloo, IA  50704

If you prefer a credit card purchase, call 888-MOM-1-POP and have credit card information ready.

	SHIPPING
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