<HEAD><TITLE>Grandparent's Book Order Form</HEAD></TITLE>
<BODY>
<H2>Grandparent's Book Order Form</H2>
<I><B>Important:</B> When you have filled out this form to your satisfaction,
click on the <CODE>SEND</CODE> button at the bottom to submit it.  If you have the Netscape browser, version 1.22 or later and the key
at the bottom is broken, you can 
<A HREF="https://secure.branch.com/milton/ordmilt.htm">encrypt</A>
your order for the latest in privacy and credit card security.</I>
<HR>
<P>
<FORM METHOD="POST" ACTION="/bin/order?milton">
<B>Order Information:</B><UL>
<b>$14.95 - Grandparent's Book</b><br>
<INPUT SIZE=10 NAME="quantity"> - Quantity<br>
<INPUT SIZE=10 NAME="subtotal"> - Subtotal</UL>
<P>
<P>
<B>Purchased by:</B><UL>
<INPUT SIZE=30 NAME="name"> - Name<BR>
<INPUT SIZE=30 NAME="st_address"> - Street Address<BR>
<INPUT SIZE=30 NAME="city"> - City<BR>
<INPUT SIZE=30 NAME="state"> - State<BR>
<INPUT SIZE=30 NAME="country"> - Country<BR>
<INPUT SIZE=30 NAME="zip"> - Zip/Postal Code<BR>
<INPUT SIZE=30 NAME="phone"> - Daytime Phone</UL>
<P>
<B>Payment Information:</B><UL>
<P>
<INPUT SIZE=30 NAME="subtotal"> - Subtotal<BR>
<INPUT SIZE=30 NAME="tax"> - NY residents please add 8.25% sales tax<BR>
<INPUT SIZE=30 NAME="s&h"> - $3.00 Shipping and Handling (USA)<br>
<INPUT SIZE=30 NAME="total"> - Total Amount Due<br>
<i>* International Orders Please Contact Us for Shipping and Handling Costs</i></ul></P>
<P>
Credit Card Type:<BR><UL>
<INPUT TYPE="radio" NAME="card_type" VALUE="visa"> VISA  
<INPUT TYPE="radio" NAME="card_type" VALUE="master_card"> MasterCard
<P>
<INPUT SIZE=30 NAME="card_name"> - Name on Card<BR>
<INPUT SIZE=30 NAME="card#"> - Card Number<BR>
<INPUT SIZE=30 NAME="exp_date"> - Expiration Date</UL>
<P>
<B>Send to:</B><UL>
<INPUT SIZE=30 NAME="send_name"> - Name<BR>
<INPUT SIZE=30 NAME="send_st_address"> - Street Address<BR>
<INPUT SIZE=30 NAME="send_city"> - City<BR>
<INPUT SIZE=30 NAME="send_state"> - State<BR>
<INPUT SIZE=30 NAME="send_country"> - Country<BR>
<INPUT SIZE=30 NAME="send_zip"> - Zip/Postal Code<BR>
<INPUT SIZE=30 NAME="send_phone"> - Daytime Phone</UL>
<P>
<B>Sent with Compliments of:</b><ul>
<INPUT SIZE=60 NAME="compliments_of"></ul></p>

<P>If you are unable to fill out this form, you may send your check
or money order to:
<ul>Grandparent's Book<br>
c/o Milton Kamen<br>
141 East 44th Street<br>
New York, New York 10017</ul></p>
<P>
Phone: 212-818-1750<br>
FAX:  212-818-1477</p>
<hr>
<INPUT TYPE="submit" VALUE="SEND"> - (<I>select to submit order</I>)  
<INPUT TYPE="reset" VALUE="CLEAR"> - (<I>select to clear form</I>)<P>
</FORM>
Go back to the <A HREF="milton.htm">Grandparent's Book Main Page</A><BR>
Return to the <A HREF="/index2.htm">Branch Mall</A>
<P>
<hr>
<I>Copyright 1995 Branch Information Services</I>
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