BIOPTIC DRIVING VIDEO ORDER FORM

To order the Bioptic Driving video, please print this form and mail it with your payment to:

The Low Vision Centers of Indiana
Video Request
P.O. Box 166
Hartford City, IN 47348

To order by credit card, please call (765) 348-2020 or fill out the information below. We accept Visa, MasterCard, American Express and Discover.

PLEASE PRINT

Name __________________________________________ Date________

Address ____________________________________________________

City _______________________ State ______ Province ______________

Country _______________________ Postal Codes __________________

Phone Number _______________________________________________ 

United States Residents

Enclosed, you will find my [  ] Check   [  ] Money Order or   [  ] Credit Card order for  $25.00. 
Please send me a VHS videotape copy of Bioptic Driving.

[  ] American Express   [  ] Discover     [  ] Visa       [  ] MasterCard

Credit Card Number ____________________________ Expires ________

         Signature _________________________________

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Outside the United States (Credit Cards Only)

Enclosed, you will find my credit card payment for $ 35.00. Please send me a VHS videotape copy of Bioptic Driving.

 [  ] American Express   [  ] Discover     [  ] Visa       [  ] MasterCard

 Credit Card Number ______________________________ Expires ________

Signature _______________________________________________________

 

ALL RETURNS WILL BE ACCEPTED FOR A REPLACEMENT TAPE ONLY.