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	ORDER FORM	PIERRE FAUCHARD — First Dental Surgeon To order, please complete this form and send to: Dr. James M. Brophy III, Editor 931 Glen Flora Waukegan, IL 60085 Tel: (847) 662-0299 Fax: (847) 662-0685 E-mail: PFADWJMB@aol.com Please pay in advance (international Money Order or Credit Card) in the amount of US$25.00 plus $5 postage per softcover book, or in the amount of US$35.00 plus $5 postage per hardcover book, For international orders add $6 for postage per single copy, U.S. currency only. Please allow 4 - 6 weeks for delivery Please do not send cash nor personal check. Quantity of Order: ____________________________ Amount of Order : US$ ________________________ 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 $ __________________