Teckni-Corp, Ltd., Order Form:
Bill to:                                                              

      Ship to:  ____  check if same as Bill to:

Name:  __________________________________________________

Name: ________________________________

Organization:  _____________________________________________ Organization: ___________________________
Address:  _________________________________________________  Address:  ______________________________
Address:  ______________________________ Address:  ______________________________
City:  __________________   State:  _________  City:  _________________   State:  _________
Zip:  ______________    Zip:  ______________
Phone:  __________________________

  Phone:  __________________________

Email ID:  ________________________  Email ID: _________________________
Not for Profit Tax ID #  ________________
School Videos, Books & Educational Products:         

Quantity:

Unit Price:

     Total:

Mock-U-Mentary Drunk Driving for Beginners - video

  ________

$ 99.00

_________

Mock-U-Mentary Encourage Bullying in School - video   ________ $ 99.00

_________

StudentSafe™ Bullying Awareness video program

  ________

$  149.95

_________

The StudentSafe™ School Safety video program   ________

$  149.95

_________

The Peer Mediation™ video training program   ________

$    99.95

_________

     

_________

Team Decisions - Win or Lose? Educational Game ________ $   59.95

_________

Personal Wellness & Fitness Tracking Tool - workbook

________ $   49.95 _________
The Calorie Coach Educational Game ________ $ 249.95 _________
The Drinking Can Weight Educational Game

________

       $ 249.95

_________
      _________
The Scout Law: Quotes for Life  - book ________ $   10.95 _________
Why SCOUTING - book ________ $   4.95 _________
Think B-4 You Ink: tattoo information - book ________ $   4.95 _________
Life's Lessons from MOM - book ________ $   10.95 _________
Life's Lessons from DAD - book ________ $   10.95 _________
Dear Santa, I want... an book of emails sent to Santa ________ $    9.95 _________
Follow the Arrow - Quotes for OA Boy Scouts - book ________ $  10.95 _________

Bulk Pricing on all products

call for pricing   _________

Sub Total:

     _________

Plus applicable taxes (Illinois residents) 7.25%):

     _________

Plus applicable taxes (Iowa residents) 7%):

     _________

Shipping and Handling - $4.00 per item - (maximum $12.00 per order) :

     _________

Grand Total:

     _________

Visa / Master Card Credit Card #__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ Exp. Date (mm/yy) __ __ /__ __
 
Pre-Authorized Purchase Order #  ___________________  (Standard terms are net 15 days for a P.O.):
Please make checks out to Teckni-Corp, Ltd. and allow 1- 2 weeks for standard delivery.
Phone: 563-359-4388             Fax: 563-359-4671
Fax form or mail to:
Teckni-Corp, Ltd.  
PO BOX 866
Bettendorf,  IA  52722

For additional information, please visit our web site at: www.studentsafe.com


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