This is the basic information we need about your organization
or the designated individual to receive the commissions.

Name___________________________________________________________________

Name 2_________________________________________________________________

Address_________________________________________________________________

Address 2_______________________________________________________________

Social security number ____________________________________________________

Or, Federal Employer Number (FEIN)________________________________________
Telephone number________________________________________________________
Email address____________________________________________________________

ORDER FORM

Price per book------------------------------------------------------$19.84
Shipping and handling-----------------------------------------------4.95
Subtotal--------------------------------------------------------------$24.79

Gift card---------------------------------------------------------No charge
Sales tax (Ohio purchasers)----------------------------------------$1.44
Sales tax (Alabama purchasers)-------------------------------------$.80

Number of books to Ohio purchasers----------________ @ $26.23 = $____________
Number of books to Alabama purchasers-----________ @ $25.59 = $____________
Number of books to other purchasers----------________ @ $24.79 = $____________
Total remitted----------------------------------------------------------------- $____________
Date______________

Wealthy World Publishing Co.
15 Office Park Circle, Suite 204
Birmingham, AL 35223
Tel 205-879-6600  Fax 205-879-6601