MediaWise Order Form

NIMF

Product Order Form

To Order by Phone, Please Call Toll-Free 1-888-672-5437 or 612-672-5437. To order, simply print out this page, fill it out, and mail to: National Institute on Media and the Family, 606 24th Ave. So., Suite 606, Minneapolis, MN 55454. Or fax to: 612-672-4113

Ordered By:

Name (please print)________________________________________________

Address ________________________________________________________

City, State, Zip ___________________________________________________

Day phone _______________________

Email __________________________

Ship To: (if different than ordered by)

Name (please print) ________________________________________________

Address _________________________________________________________

City, State, Zip ___________________________________________________

Day phone ________________________

Email __________________________

ITEM #	PRODUCT NAME	QUANTITY (x)	PRICE (=)	TOTAL





			Subtotal:
			MN Sales Tax*
			Optional Donation**	$5.00
			Shipping & Handling***
			TOTAL:

* MN Sales Tax: Orders shipped within Minneapolis city limits, please include 7% sales tax. Orders shipped within Minnesota, please include 6.5% sales tax.

Method of Payment

Check or Money Order payable to National Institute on Media and the Family

Purchase Order Number (if applicable):________________________________

Bill my credit card: Visa Mastercard Discover

Number: ________________________________________

Exp. Date: ______________________________________

Your Signature:_______________________________

Tax Exempt ID Number (if applicable):____________________________

** Help Make an Impact! Add a $5.00 donation to your total and help us continue distributing our information and materials across the country.

Call 888-672-5437 for quantity discounts.

***Shipping and Handling Charges

Order Subtotal Charge

$    1.00 - $ 10.00 =   $5.00
$ 10.01 - $ 50.00 =   $7.00
$ 50.01 - $ 75.00 =   $8.00
$ 75.01 - $150.00 = $ 9.00
$150.01 - $200.00 = $10.00
$200.01 - $500.00 = add 7%
$500.01 - $800.00 = add 8%
$800.01 and up     =   add 9%

Prices and items are subject to change and availability.
For further information call toll-free: 888.672.5437