* Denotes Required - Do Not Leave Space Blank

  *  First Name
  *  Last Name
  *  Address

  *  City
  *  State / Province
  *  Country
  *  Zip / Postal Code
  *  Daytime Phone #
  *  Evening Phone #
      E-Mail Address

Video Format                   VHS         DVD         PAL

Payment Method *          Check       Money Order      Credit Card 
   
* Make checks/money orders payable to "International Martial Arts Association"
* Outside of US, ONLY checks accepted are Travelers Checks
* If you are paying by check or money order, please send your  check or money order to the address at the bottom of this form, with VIDEO/BOOK ORDER in the memo space.  Your order WILL NOT be shipped until the check has cleared, but the materials you order WILL BE RESERVED FOR YOU at the CURRENT PRICE!

Credit Card Type             Visa    MC    American Express 
Card Number                   
Expiration Date                Month 01 02 03 04 05 06 07 08 09 10 11 12    Year  2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

      ITEM                                                               UNIT PRICE   QTY          TOTAL

VIDEO - 3 TAPE SET (Vol 1, 2 & 3)             ($99.99 US)        $

NEW-Single Video - Intro - Basic Techniques  ($34.99 US)        $

Single Video - Vol 1 - Beginner                          ($34.99 US)        $

Single Video - Vol 2 - Intermediate                    ($34.99 US)        $

Single Video - Vol 3 - Advanced                         ($34.99 US)        $

Book - One Step Manual                                   ($14.95 US)        $
                                                                                    ____________________________

                                                                                           SUBTOTAL     $  *