Order Form for Positive Attitudes positive thinking Affirmations and Actions to Help Survive Your Cancer Experience and for Overcoming Your Health Challenges by Brent Atwater, medical intuitive and distance bioenergy healer.

Order Form:
You may print out this form, fill it in and send it along with
credit or debit card information or a check or money order
payable to: Collections, Inc or Pay Pal Email: Brent@BrentAtwater.com


Please send to:
                   B Brent Atwater
                   PO Box 475
                   Southern Pines, NC 28388

NC Phone: 910-692-5206 or Atl, GA 404-242-9022 USA
NC Fax: 910-692-5103

Use one form for each Book.
Be sure to add $ 1.85 for shipping, delivery confirmation.
Please check with us for international shipping rates.
Thank you for your purchase!

1. Name of Book/ Manual: _____________________________________________

2. Price: ________________________________________________

3. Quantity:___________________

Ordering Information:		Shipping Information, if different:
Name		Name
Address		Address
Address		Address
Address		Address
Phone
Email	_________________________
Name and address on Credit or Debit card:	________________________________________ ________________________________________ ________________________________________ ________________________________________
Credit or Debit card type:		Expiration date: and 3 digit Security code on back of signature strip	_______________
Credit or Debit card number:

Pay Pal Account information:_________________________________________________

                                           _________________________________________________

If I pay by debit or credit card, I understand that by providing the following information
to Ms. Atwater, and Collections, Inc., that I agree to and I legally authorize that
the debit or credit card above be charged to pay for the book(s).
If I pay via PayPal, I agree to and authorize a PayPal transaction to pay for the book(s).

I understand and agree to the fact that my order must be prepaid and is
non refundable. All sales are final.

I am eighteen (18) years of age or older, of sound mind, and not under any mind altering
drugs.
By signing this agreement, I acknowledge that I have read the above, have thoroughly
reviewed and understand its contents, and that I am giving my informed consent and
it is my intent to agree to this contract.  By my written acceptance of this agreement,
I know this document becomes a legally binding contract.

Name:________________________________________________________________( Seal)
Date: April 07, 2008                                                  Insurance Shipping delivery conformation: ______________

                All prices at US currency rates TOTAL AMOUNT DUE: ______________________

                                                                                 Date Paid: ______________________

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