Snail-Mail Order Form

Snail-Mail Order Form
DutchClarke.com
No information contained on this form will be sold, shared or otherwise reveled to any third party.
We have a NO SPAM policy!

US & Canadian Orders:
Mail: (checks or money orders)
Media West
PO Box 2849
Gearhart, OR 97138 USA
Fax: (credit card orders only)
1.503.717.9180

International Orders:
Send money orders to mailing address
Add US$4.00 for each book shipped overseas.

Billing To Information:

First Name

Last Name

Company

Address

City

State

( Province if other than U.S. )

Country

Zip/ Postal Code

Daytime Phone#:

Email Address

Order Confirmation Will Be Sent To The Above Email Address

Ship To Information:

Name:

Address:

City:

State

Country:

Postal Code

Book Order:

Credit Card

Card Number

Expiration Date

Name As It Appears On Credit Card

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