Motherland Printable Order Form

You may either blank and fill it out by hand or fill it out on the computer and print it.

Shipping Address:

Name: *
Company:
Addr 1: *
Addr 2:
City: *
State: * Zip: *
Phone:
Email:

Billing Address (if different):

Name:
Company:
Addr 1:
Addr 2:
City:
State: Zip:
Phone:
Email:

Product / Shipping / Payment

Motherland (English): x $17.99 =
Part I (Russian): x $15.99 =
Part II (Russian): x $19.99 =
Part III (Russian): x $16.99 =
Shipping & Handling: ($3.49 for 1st + $0.65 per each additional)
Sales Tax: (9.50% on shipments to CA only)
TOTAL: *

Visa MasterCard Amex Discover
Card #: Exp:
IMPORTANT: 'intelliHoldings' will appear as the seller on your credit card statement.

Check (make payable to 'intelliHoldings')

Signature _________________________________________*

Fax the first page of this form to (866) 242-0083 (credit card payment only) or mail it along with your full payment to:

intelliHoldings
Attn: Motherland
P.O. Box 22234
San Francisco, CA 94122