List of all Selene CD's

ORDER FORM

From: _______________________________________

Street: _______________________________________

City: ________________ State: ___ Zip: ___________

Phone: ______________________________________

E-mail: _______________________________________

Send to:

Poland Import Export, 4216 Bettina Ave., San Mateo, CA 94403
Tel. 650.341.7359 fax 1.650.341.7359

ITEM TITLE CAT.# PRICE Q-TY EXT.

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7

SUBTOTAL

INTERNATIONAL ORDERS ADD S&H

CALIFORNIA RESIDENTS ADD SALES TAX

TOTAL

Credit card #: ______________________________________________

Expiration date: ____________________

Name on the card: ___________________________________________

Signature: _________________________________________________

ITEM	TITLE	CAT.#	PRICE	Q-TY	EXT.
1
2
3
4
5
6
7
SUBTOTAL
INTERNATIONAL ORDERS ADD S&H
CALIFORNIA RESIDENTS ADD SALES TAX
TOTAL