QIGONG INSTITUTE

Order Form

Fill out section 1 and 2. Print the form and mail to The Qigong Institute, 617 Hawthorne Avenue, Menlo Park, California 94024, U.S.A. Please allow 3 weeks for delivery. Contact the Qigong Institute for instructions for rush or special orders.

To use a credit card, send a copy of this order and your name, card type, card number, and expiration date by mail or email qi@qigonginstitute.org

Section 1: Customer Information

Please make checks or money orders payable to the Qigong Institute, and mail to:

The Qigong Institute, 617 Hawthorne Avenue, Los Altos, CA 94024 USA

To use a credit card, send a copy of this order and your name, card type, card number, and expiration date by mail, or email qi@qigonginstitute.org

Name ____________________________________________________________

Address __________________________________________________________

City ________________________________ State _______Zip ______________

Phone: __________________________ email: ____________________________

Credit Card (circle): MasterCard / Visa / Discover / American Express

Card Number: _________________________ Expiration Date: _______________

Actual Name on the Credit Card _______________________________________

Section 2: Order Description

&#Please refer to the table of "Materials for Sale" in the Website.

Total cost of items.............................................. $ _____________

California Resident Sales Tax (8.25%) ............... $ _____________

Shipping *.......................................................... $ _____________

Amount Enclosed ............................................ $ _____________