Printable Mail Order Form Palmer Smoking Clinic
| Compact Disk | Price | order |
| Custom Hypnosis CD | $250.00 ** | _______ |
| Customized Sports CD * | $250.00 ** | _______ |
| Secrets of Quitting (no hypnosis) | $39.95 | _______ |
| (Return to home page) | Subtotal | _______ |
| Secrets of Quitting Only, USA Shipping and Handling | $6.00 |
| Illinois Res. Tax at .07 × Subtotal amount | _________ |
| Outside USA, S& H add $5.00 | _________ |
| TOTAL | _________ |
Payment Choices: Visa/Master Card, Money Order, Personal Check (allow 3 weeks)
Name: ______________________________Email or USA Phone________________________
Address _____________________________ City ___________________State____ Zip______
Visa/MC Cardholder_________________________ Card Number________________________
Date_________
Card holder signature:________________________________
* Customized Sports CD: Remember to include questionnaire.
Link To
Questionnaire
** includes interview time, Custom CD and shipping