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ORDER FORM

LEGACY, THE DENTAL PROFESSION Philosophies and Thoughts of Selected Dental Leaders Worldwide To order, please complete this form and send to: P.F.A. Foundation - Legacy 1441 Avocado Avenue, Suite 508 Newport Beach, California 92660-7791 FAX: 949-721-9146 Please pay in advance (international Money Order or Credit Card) $ 35.00 U.S. per copy, Includes postage & handling ( California residents add 7.75 % sales tax. ) For international orders add $5 for postage per single copy, U.S. currency only. Please allow 4 - 6 weeks for delivery Cost: ______ International postage & handling/copy ______ Sales tax (California Residents) ______ Total enclosed $ USD ______ Please make your tax deductible check or money order payable to: P.F.A. Foundation - Legacy (P.F.A.) Pierre Fauchard Academy Orderer: _________________________________________________ ...................DR. Mr. Mrs. Miss. Ms. SHIP TO: Mailing Address______________________________________________ Mailing Address______________________________________________ City_____________________________State________Zip Code________ Country_______________________ Your Daytime Phone Number:_______________________________ FAX Number:_____________________________________________ Payment Amount Enclosed International Money Order: USD $ ____________