In the Shadow of Chance: The Pathological Gambler -- Order Form
BOOK ORDER FORM
In the Shadow of Chance is available through the Nevada Council on Problem Gambling at a cost
of $13.00 each [includes shipping and handling within the
Name: _______________________________________________Date: ____________________
Company:
______________________________________________________________________
Address:
_______________________________________________________________________
City: _________________________________ State: ________ Zip: _____________________
Phone: __________________________________Fax:
__________________________________
Email:
_________________________________________________________________________
Quantity Ordered ___________________
x $10.00 = $______________
Total Amount Due
PAYMENT: □ Cash / Check
/ Money Order enclosed
□ Bill total to □Visa □MasterCard # _____________________________ Exp. Date: __________
Signature:
_____________________________________________________________________
(Required
for Credit Card payment)
Mail Completed form and payment to: Nevada Council on Problem Gambling
4340
S. Valley View,
Phone:
702-369-9740 Fax: 702-369-9765
Website: nevadacouncil.org Email:
nevcouncil@aol.com
Office Use Only:
Receipt # ____________ Date:____________ Check #__________________ Amount _______________