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Chipley-Pine Mountain Video Order Form

To order, please print this page (choose FILE, PRINT from your browser's menu)
and postal mail this form along with your check or money order to:

Chipley Historical Society, PO Box 1055, GA 31822, Phone 706 663-4044

Name ________________________________________
Address ________________________________________
City ____________________ ST ____ Zip _________
Country ________________________________________
Phone________________________________________
E-mail________________________________________

QTY. ITEMPRICETOTAL
____Celebrating Our Heritage VHS Video$19.95$______
____ U.S. Shipping4.00$______
____ Foreign Shipping5.00$______
  SUB TOTAL$______
GRAND TOTAL$______

The Chipley Historical Center is a non-profit organization dedicated to the preservation of our vanishing Southern heritage. Contributions are tax deductible.

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