Gift Order Form
Your Billing Information
E-mail
Name
Admiral
Airman
Alderman
Ambassador
Archbishop
Attorney
Bishop
Brother
CWO
Cadet
Captain
Captn & Mrs
Cardinal
Chief
Colonel
Commander
Congressman
Dr
Dr & Mr.
Dr & Mrs
Elder
Ensign
Father
General
Governor
Honorable
Judge
LT
LT & Mrs
LT Cdr
LT Col
Lady
Lord
Madam
Major
Master
Master SGT
Mayor
Miss
Most Rev
Mother
Mr
Mr & Mrs
Mrs
Ms
No Title
PFC
Pastor
President
Private
Professor
Rabbi
Rev & Mrs
Reverend
Secretary
Senator
Senora
Senorita
Sergeant
Sir
Sister
Staff SGT
Superior
Address
(Street, PO Box, Route)
(Apt., Suite, Unit etc.)
City
State/Prov.
Select State/Province
AA
AE
AP
Alabama
Alaska
Alberta
American Samoa
Arizona
Arkansas
British Columbia
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Manitoba
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
N.W.T.
Nebraska
Nevada
New Brunswick
New Hampshire
New Jersey
New Mexico
New York
Newfoundland
North Carolina
North Dakota
Northern Mariana Islands
Nova Scotia
Nunavut
Ohio
Oklahoma
Ontario
Oregon
Palau
Pennsylvania
Prince Edward Island
Puerto Rico
Quebec
Rhode Island
Saskatchewan
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Island
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Yukon
Zip/Postal Code
Country
Aden
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia
Botswana
Bouvet Island
Brazil
British Virgin Isl
British West Indies
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Chad
Chile
China
Christmas Island
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Croatia
Cuba
Cyprus
Czech Rep
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Eq Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji Islands
Finland
France
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle Of Man
Israel
Italy
Ivory Coast
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Republic Of
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
N Korea
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Guinea
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Norway
Oman
Pakistan
Palau
Panama
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Qatar
Reunion
Romania
Russia
Rwanda
Samoa
San Marino
Sao Tome
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
St Kitts & Nevis
St. Helen Islands
St. Lucia
St. Pierre-Miquelon
St. Vincent
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad & Tobago
Tunisia
Turkey
Turkmenistan
Turks & Caicos
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Us Minor Outlying Is
Uzbekistan
Vanuatu
Vatican
Venezuela
Vietnam
Virgin Islands, Us
Western Sahara
Yemen
Zambia
Zimbabwe
Enter Payment Information
(Note that this
IS
a secure site.)
Credit Card Type
Credit Card Number
Exp. Date:
01
02
03
04
05
06
07
08
09
10
11
12
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
OR
Check here if you would like us to bill you later (US Only)
Select Offer
U.S.
12 issues for $27.00
,
additional gifts $22
24 issues for $49.00
,
additional gifts $44
Canadian
12 issues for US$39.00
,
additional gifts $34
24 issues for US$73.00
,
additional gifts $68
International
12 issues for US$51.00
,
additional gifts $46
24 issues for US$97.00
,
additional gifts $92
If you prefer not to use the online form, you may call (800) 266-4066 (U.S. and Canada) or (386)447-2398 (International). You can also write to P.O. Box 420235, Palm Coast, FL 32142-0235.
© 2010 Black Belt Magazine