You may either:
1. Complete and print this form and mail it to:
Equine Therapeutic Center, Inc.
Post Office Box 882
Hardy, VA 24101
OR
2. Complete and print this form, call 540-721-4545 and leave the requested information.
| Qty. | Description | Unit Price | Amount |
| Facilitated Healing Through Myofascial Release | $ 60.00 | ||
| Canine Myofascial Release (CD Format) | $ 60.00 | ||
| Sales Tax 5% (Virginia residents only) | |||
| Shipping / Handling (International add $6.95) | 4.95 | ||
| ———— | |||
| TOTAL DUE | ——> |
| Name: | _______________________________________________ |
| Address: | _______________________________________________ |
| City, State, ZIP: | _______________________________________________ |
| Phone: | _______________________________________________ |
| E-Mail Address: | _______________________________________________ |
| MC / Visa Card #: | _______________________________________________ |
| Expiration Date: | _______________________________________________ |
| 3 Digit Security Code (on back of card): | _______________________________________________ |
| Signature: | _______________________________________________ |
