Splashes From The River Inc.

COZY EDUCATIONAL PRODUCTS - ORDER FORM
(prices listed are in U.S. dollars)

Print form and Fax to:1-250-286-4543

Or Mail to: Splashes From The River Inc. 633 Birch Street Campbell River, BC CANADA V9W 2T2

Phone: 1-800-201-2280     Fax: 1-250-286-4543

Cheque or Money Order enclosed ____Visa ____Mastercard ___ Discover ___ AMEX ____

Credit card number __________________________Expiry date __________

Name as it appears on my card: _______________________________

Please send my order to: (NAME)________________________________________

ADDRESS: ___________________________________________________________

CITY:______________________________________________STATE _____ZIP CODE:____________

PHONE: _________________________  E-MAIL: ________________________

(please provide E-mail address if you wish to receive confirmation when your order is shipped)