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 Bill To:

Name: _____________________________________

Position: ____________________________________

Organization: ________________________________

Address: ___________________________________

_____________________________________

City: _______________________________________

State: ______________________________________

Zip: _______________________________________

 Ship To:

Name: _____________________________________

Position: ____________________________________

Organization: ________________________________

Address: ___________________________________

_____________________________________

City: _______________________________________

State: ______________________________________

Zip: _______________________________________
Qty. Title Cost/each Total
  Dreams of Denial $32.95  
  Choices $19.95  
  Relapse Prevention Guide $9.95  
  Clinical Approaches $39.95  
  American Sign Language Interpretation of the Twelve Step Program $24.95  
  National Clearinghouse Catalog Free  
Total Order Amount $____________
Shipping and Handling ($5.00 on orders of $50.00 or less; 9% of order amount on orders of $50.01 or more. (No shipping required for orders of the catalog only) $____________
Grand Total $____________

Please make checks, money orders, or purchase orders payable to The Minnesota Chemical Dependency Program for Deaf and Hard of Hearing Individuals. Mail payment and this order form to: The Minnesota Chemical Dependency Program for Deaf and Hard of Hearing Individuals, 2450 Riverside Avenue S., Minneapolis, MN 55454.