DVD Order Form

Please fill in ALL information fields and do not forget to "Submit" at the end.

Each DVD is individually priced at $25.00.
Multiple DVD's can be purchased at once.

Payment by Credit Card must be completed by calling
Cherise Murphy at 217-581-2019.
(Note: please submit this order before calling)

Payment by Check or Money Order (along with a copy of this form) can be sent to:

Illinois Higher Education Center
Eastern Illinois University
600 Lincoln Avenue
Charleston, IL 61920-3099

Telephone: 217/581-2019
FAX: 217/581-8330 (Unsecure - Shared Fax)
FEIN# 37-6013590

We are sorry but we cannot accept Purchase Orders (P.O.) at this time.

Today's Date / MM / DD YYYY
Name * First Last
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Choice of DVD(s) * $25.00 each - Motivational Interviewing with Scott Walters $25.00 each - Spin the Bottle Sex, Lies, and Alcohol with Jackson Katz and Jean Kilbourne $25.00 each - Which Brain Do You Want? with Daniel Amen, M.D.
Each DVD is $25.00. Multiple DVD's may be ordered at once.
Payment Option * Credit Card: Please call Cherise Murphy to complete transaction 217-581-2019 Check Money Order
Payment to be made: * $ . Dollars Cents
Please enter the total amount for all DVD's that will be purchased.
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Phone (if you have an extension # please add to comments above) * - (###) - ### ####