To E-mail Master Card or VisaOrders, Complete And Submit This Form:

Your E-mail:

Mr Miss Mrs Ms

First Name: Last Name:

Address: Apt. #:

City:

State / Province: Zip / Postal Code:

Country:

Telephone: Fax:

FOR ORDERING; Marriage Enrichment's Relationship Program;

as a couple ($79.95):, as a single ($69.95):

FOR ORDERING; Book: Audiocassette: Video:

Title of Product (s)-----------------------Cat # (s)-----------------------Price (s)

Total Amount of Order (s): (all amounts in US funds)

Method of Payment: Master Card: Visa:

Card #: Exp. Date: