Video Order Form Mail to: Candlelighters Childhood Cancer Foundation Canada 55 Eglinton Avenue East, Suite 401 Toronto, Ontario M4P 1G8 Phone: (416)489-6440 Fax: (416)489-9812 (Please print) Name:______________________________________________________________ Address:___________________________________________________________ ___________________________________________________________________ City/Prov.:________________________________________________________ Postal Code:________________________ Telephone:____________________ Order Amount: $________________________ Shipping and Handling Canadian orders add 5%________________ Foreign orders add 15%________________ Subtotal: $___________________________ plus GST 7% __________________________ Final Total:$_________________________ (Check one) ____ Enclosed is my cheque to Candlelighters Canada ____ I would like to charge my purchase to: ____ Visa ____ Mastercard Card No.:_______________________________ Expiry Date:____________________________ Signature:______________________________ Candlelighters accepts Purchase Orders from hospitals and organizations. Formal Purchase Orders must be mailed or faxed. All other orders must be prepaid, including shipping and handling charges. Please note: All prices subject to change without notice. Title Ordered Code Qty Price Total -----------------------------|--------|-------|---------|---------| -----------------------------|--------|-------|---------|---------| -----------------------------|--------|-------|---------|---------| -----------------------------|--------|-------|---------|---------| -----------------------------|--------|-------|---------|---------| -----------------------------|--------|-------|---------|---------| -----------------------------|--------|-------|---------|---------| -----------------------------|--------|-------|---------|---------| -----------------------------|--------|-------|---------|---------| -----------------------------|--------|-------|---------|---------| -----------------------------|--------|-------|---------|---------| -----------------------------|--------|-------|---------|---------| -----------------------------|--------|-------|---------|---------| -----------------------------|--------|-------|---------|---------| -----------------------------|--------|-------|---------|---------| -----------------------------|--------|-------|---------|---------| -----------------------------|--------|-------|---------|---------| -----------------------------|--------|-------|---------|---------| -----------------------------|--------|-------|---------|---------| I would like to borrow the following, and have enclosed a $25.00 cheque or money order for each video, payable to Candlelighters Childhood Cancer Foundation Canada. I understand that $5.00 will be retained to cover shipping and handling. Title to Borrow Code ----------------------------------------------|-------------------| ----------------------------------------------|-------------------| ----------------------------------------------|-------------------| ----------------------------------------------|-------------------| ----------------------------------------------|-------------------| ----------------------------------------------|-------------------| ----------------------------------------------|-------------------| ----------------------------------------------|-------------------| ----------------------------------------------|-------------------| ----------------------------------------------|-------------------| ----------------------------------------------|-------------------|