Autism Coach Order Form

6670 Sauk Trail, Saline Michigan  48176, email info@autismcoach.com,  web site www.autismcoach.com,fax 877-485-1440

Ship to: 

 Phone (required):

  

 Name:

  

 Street Address:

  

 City/State/Zip:

  

 Email:

  

Bill to: (only if different from Ship to)

 Phone (required):

  

 Name:

  

 Street Address:

  

 City/State/Zip:

  

 Email:

  

Order:

 Quantity

 Title

 Item Number

 Price

 

      

 

      

 

      

 

      

 

      

If you are paying by check or money order for orders over $100 (for U.S. customers only) - deduct $5 from your order total

    
*  Shipping and handling for U.S. customers who mail in a check or money order by 2nd Day Priority mail are: $7.50 for orders under $50, $9.50 for orders  $50-$149, $11.50 for orders from $150-$249, $15.50 for orders $250- $500, $25.50 for orders under $2000, and free shipping for orders over $2000.  International customers, please email autismcoach@cs.com to obtain a quote on shipping costs before placing your order.   

Subtotal

  

Shipping and Handling*

  

Total

  

Payment:

Payment Enclosed (check or money order).  Please make checks payable to Autism Coach.
Charge to:  ___  Master Card    ___  Visa
Account #   ______________________________________________________________
Expiration Date  __________________________________________________________
Signature _______________________________________________________________  
Please bill purchase order # ________________________________________________