Print this form and fill out all applicable fields below. Please print information. Fax: 978-741-2015 for credit card orders. (Be sure to call us before faxing since our fax line is shared with our computers and we want to make sure the the line is free for you to send your order. Phone: 978-744 5583) For checks, make checks payable to: MoonDragon Birthing Services MoonDragon.org accepts checks in U.S. currency drawn from U.S. banks only. The checks must be MICR encoded. Mail to: MoonDragon Birthing Services 0 (Zero) Boardman Street, Suite #1 Salem, Massachusetts 01970-4006 USA Billing & Shipping Address: Name __________________________________________________________________ Address __________________________________________________________________ __________________________________________________________________ City __________________________________________________________________ State _______________________________ Zip Code__________________________ Is shipping address the same as billing address? [ ]Yes [ ]No If No, please include information under delivery instructions. Phone __________________________________________________________________ Fax __________________________________________________________________ Email __________________________________________________________________ Credit Card Info: (if applicable) [ ]Visa [ ]MasterCard [ ]American Express [ ]Discover Credit Card Name__________________________________________________________ (As it appears on your credit card) Number ______________________________ Exp__________ Security Code________ Customer Signature:_________________________________ Date_________________ Product Information: Product Name __________________________________________________________ Quantity ___________________ Product Number________________________ Product Price __________________________________________________________ Delivery Instructions ____________________________________________________ __________________________________________________________________________ __________________________________________________________________________