Gaston and Porter Health Improvement Center
  
 
Prime Time™ Autographed Copy
Order Form
Print order form and mail to address below
Along with your check or money order
 
Name
 _________________________________________________________________
Address
 _________________________________________________________________
City, State Zip
_________________________________________________________________
Phone
 _________________________________________________________________
E-Mail
 _________________________________________________________________
Autograph
Details
Both authors will be autographing your copy of Prime Time™ please indicate the name of the person to whom the book should be autographed below:

Name of person: _________________________________________
Cost of Book
Number of copies (___) x 20.00(usd) = __________
Shipping & Handling
Number of copies (___) x 5.00(usd) = ___________
Total Amount
________________________________________
 

Mail Order Form To:

THE GASTON AND PORTER HEALTH IMPROVEMENT CENTER
8612 TIMBER HILL LAKE
POTOMAC, MD 20854

 
E-Mail
 gastonandporter@gastonandporter.org
 
 
© 2006 Marilyn Hughes Gaston, M.D. and Gayle K. Porter, Psy.D.