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| STEP 1: ORDER AND DONATIONS |
| I would like
copies of the book Copies of the book Saving Your Sex Life:
A Guide for Men with Prostate Cancer (Book $17.95 plus $4.00 s/h
Or buy both this book and "Intimacy with Impotence" for $27.50 plus 6.00 s/h US only)(International Shipping is $13.00 and includes Canada and Mexico) |
| I would like
copies of the book Copies of the book INTIMACY with IMPOTENCE: The Couple’s
Guide to Better Sex after Prostate Disease ($14.00 US only plus $4.00 shipping)
(International Shipping is $13.00 and includes Canada and Mexico) |
| I would like
copies of the book A Patient's Guide: Urinary Incontinence Control using External Urethral
Compression Devices (Clamps) ($14.00 US only plus $4.00 shipping)
(International Shipping is $13.00 and includes Canada and Mexico) |
I would also like to included a tax deductable contribution:
$20
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$35
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$50
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$100
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$500
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OTHER
$
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| STEP 2: CONTACT INFORMATION |
| Name (F/L) |
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| Address |
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| Line 2 |
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| City |
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State
(enter only for US and Canada) |
| Zip |
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| Country |
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| Phone |
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| E-mail |
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| STEP 3: PAYMENT CHOICE |
| Pay by |
check or money order (mailing address will appear after you hit the Submit Button below)
-- OR --
Secure Credit card payment via PayPal (does not require PayPal account) |
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- If you want to ship the book(s) to a different
address, indicate in the notes field below.
- After your press the submit button, TO COMPLETE YOUR PAY BY CHECK ORDER SEND YOUR CHECK TO: CIACT,
P.O. Box 341388,
Bethesda, MD 20827-1388
Phone: 301-983-9702 - Make check payable to: CIACT (This information is also on your confirmation page and confirming email)
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| STEP 4: HOW HEARD AND NOTES |
How did you hear about the book
or the website:
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Notes:
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| STEP 5: EASY DONATION OPTION |
I would like pay $25 per book (includes shipping) and make a $7 per item tax deductable donation to CIACT. |
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| STEP 6: SEND ORDER/DONATION |
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(no fields above should contain website URLs)
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