Name:

Dance Name/Organization name

Address:

Phone:

Fax:

Email:

Vendors are invited to inquire about wholesale prices.

Visa, Mastercard, or American Express Card #  (For additional security, send the last four digits of the credit card number via separate e-mail):

Expiration Date:

I hereby authorize Shareen El Safy to charge the above total amount to my credit card.

Type Initials:

Or send personal check, cash or money order to:

Shareen El Safy

PO Box 90936

Santa Barbara, CA, USA

93190-0936

Foreign: International money order or bank draft (that draws funds on a U.S. bank), credit card or cash only.

Telephone/Fax: 805/962-9639.