Pathways Herbals Order Form

Please provide the following contact information:

Name
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
FAX
E-mail
URL

Please provide the following ordering information:

Qty	Product Description

Choose one of the following options:

Pick-up Shipment

	Shipping Address
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country

*If you chose the shipping option, you must send a check to the address below
including the shipping amount of $2.99.  Orders meant for pick-up can be paid
for in cash, check, or credit card.

Mail Checks to:

Pathways to Healing
Attn: Ann Piccone
1817 Bernville Road
Reading, PA 19601

Enter today's date:

-- mm/dd/yy