Private Mind Records · P.O. Box 2064 · Falls Church, VA 22042-0064
Private Mind Records Mail Order Form
Print out this form, complete, and send to:
Private Mind Records
P.O. Box 2064
Falls Church, VA 22042-0064
| ORDER: | |||||
| ___Mike Shupp/This Time CD (Available 09/27/2002) | $10.99 | Quantity: | ______ | ||
| ___Mike Shupp/The Key CD | $10.99 | Quantity: | ______ | ||
| ___Mike Shupp/October Sun CD | $10.99 | Quantity: | ______ | ||
| ___Mike Shupp/A Little Fun Cassette Single (limited edition) | $ 2.99 | Quantity: | ______ | ||
| Shipping/Handling: | |||||
| ___Domestic (1) Item: | $ 2.25 | ||||
| ___Domestic Each Addl. Item Add: | $ 1.50 | ||||
| ___International (1) Item: | $ 4.75 | ||||
| Total Amount: | ______ | ||||
| SHIPPING INFORMATION: | |
| Name: | ______________________________ |
| Address: | ______________________________ |
| City, State, Zip: | ______________________________ |
| Country: | ______________________________ |
| E-mail: | ______________________________ |
| PAYMENT INFORMATION: | |
| ___Check or Money Order: | |
| Make check or money order payable to Private Mind Records and send with this form. | |
| ___Credit Card: | |
| ___Visa ___MC ___Amex ___Discover |
| Card Number: | ______________________________ |
| Expiration: | ______ |
| Signature: | ______________________________ |
Private Mind Records · P.O. Box 2064 · Falls Church, VA 22042-0064