Please print this form, fill it out, and mail it with your check or money order to:

Ohio Center for Sport Psychology
21625 Chagrin Blvd., Suite 200,
Beachwood, OH, 44122. 

Shipping and handling charges

First item . . . . $3.00                Each additional item add . . . . $1.00

(Canadian and overseas postage and shipping add $5.00 extra to above.)


Name __________________________________

Address _________________________________

________________________________________

________________________________________

Phone____________________

Email ____________________

You may charge your order to a VISA, Discovery, or MasterCard issued from a U.S. bank.  If you wish do do so, please provide the following information:

Circle one:    VISA    Discovery     MasterCard

Name as it appears on your card ________________________

Billing Address

Card Number ________________________________________ 

CVV Number ____________ (last three digits on back of card)

Expiration Date ______________________________________

Your signature authorizing this charge ____________________

Amount to be charged   _________________________

Charges will appear on your credit card statement as ProfessionalCharges.com