Challenged America: Giant Steps Order Form

GIANT STEPS VIDEO ORDER FORM

NAME:_________________________________________________ DATE: ________________

SHIPPING ADDRESS: __________________________________________________________

_______________________________________________________________________________

BILLING ADDRESS: ___________________________________________________________

_______________________________________________________________________________

CREDIT CARD #: ______-______-______-______ EXP. DATE: __________________

I would like to purchase _________ copies of the award-winning Giant Steps Video @ $17.95 each.

Please ship: ____ Next Day Air UPS ($15.00 per item)
____ Second Day Air UPS ($10.00 per item)
____ Ground UPS ($3.00 per item)

I Authorize the total amount of $_____________ to be charged to my credit card.

Signed: _______________________________________ Date: ____________

Please print this order form and mail to:

Challenged America
914 Westwood Blvd. Ste. 148
Los Angeles, CA 90024

Or Fax To:

(310) 475-4720

All proceeds from video sales go to
The My Gym - Challenged America Foundation.