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Lupus in the Media

 

Southeast Florida Chapter

 
   

 

Sales Program Order Form

If your server does not support forms or if you do not get the message indicating successful transmission, e-mail you request to lupusfl@bellsouth.net. If you would prefer, you may also print the form below and mail it to this address: 75 NE 6th Ave. Suite 223 Delray Beach, FL 33483.

Please send me the following item(s) indicated on this order form. I have calculated sales tax and postage and handling. I am sending payment by mail or have indicated my credit card information. 

E-mail address:

Name:

Street address:

City:

State:

Zip code:

Daytime phone:

Evening phone:

Payment Method:

Check (Please make check payable to LFA, Inc. - Southeast Florida Chapter
 Credit Card - VISA
 Credit Card - MasterCard
 Credit Card - American Express

Account number:
Expiration Date:


Item Number & Description

Cost per Item

Quantity

Total

Sub Total

  

  

Sales Tax 6.0%

  

  

Shipping Costs *see chart below

  

  

Total Charge

  

  


Postage and Handling:
up to $7.00, add $2.00
$7.01 to $15.00, add $4.00
above $15.00, add $6.00

    


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LFA Southeast Chapter provides support and services in:
Brevard, Broward, Miami-Dade, Monroe, Okeechobee, Palm Beach and St. Lucie Counties