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(this form will require a printer)
*Please note: we donate 50% of your payment (all our profits) to
The Anxiety Disorders Association of America
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 ...
Mail signed form to:
PATHWAY SYSTEMS
P.O. BOX 269
CHAPEL HILL, NC 27514
Using the following form will speed your order and ensure mailing to proper address
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4 Easy Steps !
#1 select the item you wish to order
DON'T PANIC SELF HELP KIT...$79.95
#2 determine the amount to be billed
SUB-TOTAL
North Carolina Residents add 6% Sales Tax
Shipping ($5 in USA; Canada is $6 -US funds)
TOTAL
#3 Enter your mailing information
| Full Name |
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| Address Line 1 |
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| Address Line 2 |
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| City |
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| State |
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| Zipcode |
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| e-mail address |
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| phone number |
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#4 enter billing information , print and sign
Check / Money Order
Credit Card (type) Visa / Master Card |
Purchase order (attach purchase order)
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| Credit Card number: |
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| Expiration Date: |
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| Name (if different from above, as it appears on credit card) |
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| Address (if different from above, as it appears on credit card) |
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| Address Line 2 (if needed) |
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| City |
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| State |
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| Zipcode |
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| phone number |
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Please read: By filling out, signing and mailing 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 ________________
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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)
next: Mail or Fax Order Form
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Last Updated( Jan 22, 2009 )
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reviewed by: Harry Croft, MD
Psychiatrist, HealthyPlace.com Medical Director
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