Date:
month                         day                    year
Your name: (complete)
Your address:
# and street name DO NOT USE A  PO BOX
city                                 state                    zip
_
Your phone number:
Your email address:
Book title
Book ISBN
I understand the retail price of my book is set at  $
%
I understand the wholesale discount is set at
I understand the wholesale price is set at $
I understand that my royalty per book is $
each.
each.
I understand that I may purchase copies for $