Latino
Health Organization Educational Videos
Order Form
Place an “x” in
the space before the video(s) you wish to order.
___ Generaledades en Diabetes
(Diabetes: an Overview)
___
Diabetes
y Actividades Físicas (Diabetes and Physical Activity)
___
Diabetes
y Obesidad (Diabetes and Obesity)
___
Diabetes
y Riñones (Diabetes and Kidneys)
___
Enfermadades
de Corazón y Diabetes (Heart Disease and Diabetes)
Videos are priced at
$50.00 each for not-for-profit organizations and $65.00 each for other groups.
Shipping and handling
charges are included.
Ship
to: Name
________________________________________________________________
Address:
_____________________________________________________________
City, State, Zip
________________________________________________________
Method
of Payment: (We are sorry we
cannot process orders on a C.O.D. or personal billing basis)
__ Check or Money Order (enclosed)
__ MC/VISA Acct. number: _ _ _ _ - _ _ _ _ - _ _ _ _ - _ _ _ _
CVV2#s
_ _ _ *
Expiration Date: Month
_ _ Year _ _
Name on account (as it appears on credit card) _________________________________
Total
number of videos requested _____ Total amount ($) enclosed (charged to MC/VISA) $ ___________
* CVV2#s are
the last 3 digits of the number found on the back or your credit card in the
signature area.
Copy the above form and mail to:
Latino Health Organization, Inc.
1225 W. Mitchell Street, Suite 212
Milwaukee, WI 53204
414-647-9990
or e-mail to: rafael@latinohealthorganization.org or larry@stocksandassociates.com