Ship to: Name: _____________________________________________________

Address: __________________________________________________________

City: ________________________________State ______________Zip ________

Phone: _____________________ Email: ________________________________

Check or money order enclosed for $ ____________________

Or charge to: ___ VISA ___ MasterCard ___ Discover ___ American Express

Credit Card Number: ___________________________ Expiration Date ________

Signature (if you are charging order) _________________________________________

Mail completed form, with your payment, to:

Center for Applied Motivation
107 W. Edmonston Dr.
Rockville, MD  20852

or Fax order (if charging) to:  301-838-8525

or Call:  800-589-4567 (Mon-Fri: 1:00 p.m. -5:00 p.m. Eastern Time)

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