Leaning Out Health Care Book Order Form

Name:   Telephone Number:

Company:

  Ship-to Address:

Street 

City    

State  

ZIP     

Book order quantity:

  Up to 9 - $32.50, includes standard shipping  

   10 to 25 - $29.95, includes standard shipping  

  Form of payment: 

  Check enclosed    Will call BPCG with Credit Card information    Credit Card by FAX                                                      

Visa    MasterCard    American Express   Discover Card  

Name on Credit Card: Billing Telephone Number:

                                                           (If not the same as “Ship-to” name)                                                                           (Required)

Billing address:

(If not the same as “Ship-to” address) 

Street  

City   

State 

ZIP                                                   Email Address:

                                                                                                              (For shipping confirmation only)

Credit Card Number: 

Expiration Date:  /

Security Code:  (Three digits on reverse of card)

Please do not email credit card information for your security

 Thank you!  

Print this form by using your browser's Print feature 

to mail or fax to BPCG. 

Mail to:          BPCG                                                    Call in book order to: 720.981.1111

                        166 Willowleaf Drive                                    Fax in book order to: 720.981.1323

                        Littleton, Colorado 80127 USA

For Internal Use Only