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Purchased by: Name _______________________________________ Street _______________________________________ City, State, Zip ________________________________ Phone (if we have questions) _____________________ Today’s Date _________________________________

Remit to: CompassHealth, Inc. P.O. Box 560 New Gloucester, ME 04260 Contact Person: Sonja DeRose 580-504-2683 Notes: Please make check payable to “CompassHealth”

Date	Item Code	Description	Quantity	Amount
	VID 0301-1	“Listening to the Buffalo” (LTTB) Video: $20.00 each for 1-4 $12.00 each for 5 or more
	VID 0302-1	“19 Days to Change Your Life” (19D) Video: $5.00 each for 1-4 $3.00 each for 5 or more
	VID 0303-1	“Changing Bad Habits for Good (CBH) Video: $20.00 each for 1-4 $12.00 each for 5 or more
	BK 0401-1	Your Pet, Your Health, and The Afterlife (PHA) Book $15 each for 1-4 $10 each for 5 or more
		Subtotal
		Oklahoma Residents: Add 8% State and Local Sales Tax
		Shipping and Handling (based on subtotal) $0 - $9.99…....$3 $10 - $19.99.....$5 $20 - $59.99..…$8 $60 - $99.99.....$10 $100 or more...FREE
		Grand Total