Dr Janet G. Woititz Video Lecture on ACoA's
The Mail Order Form

This one hour lecture is available on VHS for $19.95 plus $4.00 shipping per copy.

All orders are shipped by UPS Priority Mail. Allow up to 2 weeks for delivery.

To order: Please fill out this form and send it us by postal mail.

PRINT THIS FORM
Please direct all correspondance and checks to:

David Woititz
5 Prospect St.
Bloomfield, NJ
07003
USA
Attn: Dr Jan Video

Ordered by:

Name:         ___________________________________________________________

Address:    ___________________________________________________________
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City, State, Zip:_____________________________________________________

Phone Number: ___________________________    E:Mail: __________________

Ship to: (if different than "ordered by"):

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Payment Method :
Please send a check or money order in U. S dollars:

QUANTITY	PRICE	DESCRIPTION	SHIPPING/HANDLING
	$29.95 (each)	1 VHS Video - Dr. Woititz: Adult Children of Alcoholics	$4.00 (per tape)
			Total  $_______