ADAA Fax Form - The Anxieties Site

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Fax Order Form
(this form will require a printer and fax machine)

Quick Instructions:

Fill out the form below

Be sure to check off the items you would like to purchase
Remember to include your mailing address
Include payment / credit card information
Print this form ...
Sign the form ...
Fax signed form to 1-919-942-0700

Using the following form will speed your order and ensure mailing to proper address

4 Easy Steps !

[FrontPage Save Results Component]

#1 select the items you wish to order

FACING PANIC: Self-Help for People with Panic Attacks...$15.00 NEW
DON'T PANIC (Book)...$15.00
DON'T PANIC SELF HELP KIT...$79.95
DON'T PANIC KIT plus BOOK...$89.95
ACHIEVING COMFORTABLE FLIGHT...$59.95
STOP OBSESSING...$16.00
STOP OBSESSING AUDIO TAPE SERIES...$24.95

(If you make a mistake you can hit this button) -

#2 determine the amount to be billed

SUB-TOTAL

Shipping ($5.75 for 1st item, $.85 each additional, in USA)

North Carolina Residents add 7% Sales Tax

TOTAL

#3 Enter your mailing information

Full Name
Address Line 1
Address Line 2
City
State
Zipcode
phone number
e-mail address

#4 enter billing information , print and sign

Check / Money Order	Credit Card (type) Visa Master Card
Purchase order (attach purchase order)

Credit Card number:
Expiration Date:
Name (if different from above, as it appears on credit card)
Address (if different from above, as it appears on credit card)
Address Line 2 (if needed)
City
State
Zipcode
phone number

Please read: By filling out, signing and faxing this form I authorize Pathway Systems to bill the credit card I listed above for only the items I have checked on this order form.

My signature___________________________________
Date ________________

Or call this toll-free number for a free brochure on these
Self-help resources available from Pathway Systems and Anxieties.com
800-394-2299 (toll: 919-942-0700)

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Anxieties Site

Fax Order Form (this form will require a printer and fax machine)

Fax Order Form
(this form will require a printer and fax machine)