1.  Ordered by:

Name:
 
Address:
City:
State:
Zip:
Country:
 
Telephone:
Fax:
E-mail:

Check one:

 ___ Embassy list (Cost: $60)

 ___ Consular list (Cost: $60)

 ___ Both lists (Cost: $100)


For delivery via 3.5" PC compatible disk sent by USPS add $20 for shipping and handling


 
If the e-mail should be sent to a different address than the one listed above, please note it here:

         __________________________________________


I agree that the list(s) requested are not to be resold or otherwise redistributed:

Signature: _____________________________________ 

Print out this form and send a check made out to Stapleton-Gray & 
Associates, Inc., for the appropriate amount to the above 
address.  We will send out a disk or email within 3 business days upon 
receipt of your check.

If you require one or both lists immediately, or wish to pay via 
credit card, contact us for expedited delivery/payment at mailinglist@embassy.org.