<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> </BODY>