First                                Last
Name    __________________________   Name  _________________________

email   ____________________________________________________________
        (example:  jdoe@youraddress.com)

Street  ____________________________________________________________

        ____________________________________________________________

City    ________________________  State/Prov._______________________

Zip/Post________________________  Country    _______________________

Phone   ________________________  Fax        _______________________

 __________________________________________________________________
     Quantity             Description                      Cost

                                            SUBTOTAL $
                                              S/H    $
                                              TOTAL  $
______________________________________________________________________
[ ] Check (US banks only) [ ] Money Orders (US currency only)
[ ] MasterCard  [ ] Visa  [ ] Paypal (paypal@bentcover.com)


Card Number __________________________  Expiration Date _____ / _____
                                                        month   year


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To send us your order by facsimile, fill out this form and fax it to
(602) 942-3095.  If you want to mail us your order, fill out this form and send it to:
    The Bent Cover Bookstore
    c/o Web site
    12428 North 28th Drive
    Phoenix, AZ 85029-2433
    USA

Then email us and tell us you did so. This prevents 'S-mail' being confused with a 'no-response' and the re-shelving and selling of your request.

Upon receipt of this form, we will process your order and send you a confirmation email within one business day.

If you have any questions or trouble with this form or with sending your fax, send email to richard@bentcover.com.