Gap Mangione's
CD Order Form
"Stolen
Moments," "Diana
in the Autumn Wind," "Ardis" and "Planet Gap" are available
for sale here.
To
order, please print this form, fill it out, and send it along with your payment
to the address at the bottom of the page.
Name: ___________________________________________________________________________
Address: _________________________________________________________________________
City: ___________________________________ State: ___________ Zip Code: ______________
Phone: _________________________________________________________________________
PAYMENT
OPTIONS [circle one]:
Check
/ Money Order / Credit Card
US Funds ONLY,
checks and money orders made payable to: MusicRochester,
Inc. Please do not send cash.
If
paying by credit card, please be sure to provide the following information completely
[circle
one]:
Visa / Mastercard / American Express / Discover
Card Number: ___ / ___ / ___ / ___ / ___ / ___ / ___ / ___ / ___ / ___ / ___ / ___ / ___ / ___ / ___ / ___
Expiration
Date: ___ / ___
Payment
should be sent in U.S. funds only.
Please Process My Order:
___________________________________________________________________
Signature:
I agree to pay total amount according to card issuer agreement and authorize
merchant to charge the above account.
Credit Card orders will reflect payment to Pelican Mktg & Mgmt Inc
| Number/Description |
Quantity |
Total |
|||
| Family Holidays @ $16.98 | # | $ | |||
| Stolen Moments @ $16.98 | # | $ | |||
| Planet Gap @ $16.98 |
# |
$ |
|||
| Ardis @ $16.98 | # | $ | |||
| Diana In The Autumn Wind @ $16.98 | # | $ | |||
|
|
|
|
|
TOTAL: |
$ |
Mail
to:
MusicRochester, Inc.
PO Box 12732
Rochester,
NY 14612-0732