ExecuRead Home Study Order

PERSONAL INFORMATION
PLEASE NOTE : Items marked * are required fields. If you prefer to order by mail, click here for a Fax / Mail Order Form**
LastName, FirstName :*
Company :
Title / Job position :
Country :*
City :*
State :*
Telephone (Work) :
Telephone (Home) :
Fax :
Cellular :
E-Mail Address :*
Mailing Address :*

ORDER CONFIRMATION AND PAYMENT INFORMATION

I will be paying for the ExecuRead HomeStudy Course (hardcopy) by ......
(Check applicable option)

CURRENCY
(Check applicable option)

The hardcopy version costs R741 incl RSA S&H

CHECK :
Payable to Reading Dynamics and mailed to PO Box 68152, Bryanston 2021 Gauteng, RSA
(Please Note : your course will only be shipped on receipt of payment)

CREDIT CARD (Visa, MasterCard or American Express)*
* Orders are shipped Immediately

CREDIT CARD INFORMATION (if applicable)

CREDIT CARD TYPE (Check applicable option)

CARDHOLDERS NAME :

CARD NUMBER :

For security reasons, I do not want to include my credit card number here - I will send you my credit card number and my reference number in a separate email or by fax to 011.234.1972 Enter Credit Card number (or reference number if sending card number separately).

EXPIRATION DATE :

LAST 3 NUMBERS ON REVERSE SIDE OF CARD :

INVOICE INFORMATION (if applicable)

PLEASE NOTE : Invoices are only issued on receipt of payment or on receipt of an official company purchase order and where applicable, are due for settlement within 7 (seven) days of issue.

NAME :

ADDRESS :

FOR ATTENTION OF :

COMPANY ORDER NUMBER :

I HEREBY CONFIRM MY ORDER FOR 1 (ONE) ExecuRead Home Study PROGRAM