Please print this form and send or fax to: Empower Press C/O Twin City Martial Arts 1 Yount Dr. Bloomington, IL 61704
Name
Address
City State ZIP
Phone Number
Total number of Copies
Empowering Children 14.95each
IL Residents add Sales Tax 1.05each
Shipping and Handling 3.00each
TOTAL
VISA/Mastercard Number
EXP Date
Name on Card
Signature