Video Order Form

Due to the rising costs it is necessary to raise the video prices so that we may continue to offer such a valuable resource.

There will be a $15.00 Shipping/Handling fee. Plus the taxes (no tax if on reserve, please provide tax excempt #).

Cheques Only please	Mailing Address:
Please make the cheques payable to: First Nations Breast Cancer Society	Apt. 309-1333 East 7th Avenue Vancouver, British Columbia V5N 1R6 Canada

*indicates mandatory field

Please select the Videos you would like to purchase:*

	Echoes of The Sisters: First Nations Women and Breast Cancer (breast cancer awareness)
	VHS $75.00 Canadian
	DVD $85.00 Canadian

	First Nations Breast Self-Exam (instructional)
	VHS $55.00 Canadian.
	DVD $75.00 Canadian

Name:	*
Email:	*
Address:	*
City:	*
Province/State:
Country:
Postal Code/Zip Code:
Phone:	*
Fax:

You will receive confirmation of your order within 24 hours.