Information/Order Form

If you would like to order a copy of our book or would like additional information, please fill out the form below and we will contact you.

Please Fill Out This Form Completely!

If you are placing an order, the book(s) will be shipped upon receipt of your payment.

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Additional Information Please

Optional Field are in yellow

First Name
Last Name
Address
City
State
Zipcode
Phone
Fax
E-mail address
Color book	Quantity $10 each
Black & White book	Quantity $5 each
Autism Bracelet	Quantity $15 each
Autism Key Chain	Quantity $8 each
Comments

Please remember to add $3.85 to your order for shipping & handling

Please Click on "Send It" to send this information to us! If we do not respond within 24 hours, please fill out the form and resubmit your information. Thanks for your time!

Send Payment to: Scott & Gail Selby 624 Stone Silo Circle DePere, WI 54115

Send Payment to:
Scott & Gail Selby
624 Stone Silo Circle
DePere, WI 54115