Full Name	____________________________________________________________
Company Name	____________________________________________________________
Address	____________________________________________________________
City	________________	Province/State	___________________
Postal/Zip Code	________________	Country	___________________
Phone No.	________________	Fax No.	___________________
E-mail	____________________________________________________________
Name of cardholder _________________________________________________
Card Number ______________________________________________________
Exp Date	________________	Payment	Visa Mastercard
Signature	____________________________________________________________
Payment may also be made by mail. Please make your cheque or money order payable to DR. V H Livingstone Inc. and mail to: The Vancouver Breastfeeding Centre Suite 340 - 943 West Broadway Vancouver BC V5Z 4E1 CANADA Fax: (604) 738 1231
Quantity Which product(s) are you interested in? Price* Amount   The Art of Successful Breastfeeding: A Guide for Health Professionals DVD English Home Use     Institutional Use     US$19.00 US$50.00     The Art of Successful Breastfeeding: A Mother's Guide DVD English Home Use     Institutional Use     US$19.00 US$50.00     The Art of Successful Breastfeeding: Video Spanish     Mandrin     Cantonese     VHS PAL   Home Use Only     Institutional Use     US$35.00 US$35.00 US$35.00     US$75.00     Total