Living with Lowe Syndrome Book Order Form

Name: (please print legibly)

 

Please check one: 
Check box image Parent of LS child 

Check box image Educator or Social Service Professional 

Check box image Organization/Agency 

Check box image Relative/Friend 

Check box image Medical/Scientific Professional 

Check box image Other: (please specify below)

________________________

Pricing Information. All prices in in U.S. Dollars.

Check box image $15 each USD LSA Member 
Check box image $20 each USD Non-member 

Number of books: Check box image

Subtotal: ___________________

International shipping: _________
(see below for details)

Order Total: _________________

 

* Shipping to U.S. locations is free of charge. For shipping to international locations add $10.00 USD for each book.

Street:

 

City:

 

State:

 

Zip Code:

 

Country:

 

Telephone Number:

 

E-mail address:

 

Payment Method                                                           Total amount: $____________ (U.S. dollars only; do not send cash)

Check box image Check     Check box image Money Order (please make check or money order payable to LSA)

Check box image Visa         Check box image MasterCard 


Credit Card Number:

                               

Expiration date:

         

Authorizing signature:_______________________________________________________

 
Send to: Lowe Syndrome Association, PO Box 864346, Plano, Texas 75086-4346 USA. Allow three weeks for delivery. Book will not be shipped until payment has cleared.