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ORDER FORM – JACK DEEBLE INTERVIEW

Please print this order form and fax it to (02) 6201 9494 or post it to Publications, Australian Academy of Science, GPO Box 783, Canberra ACT 2601.

Telephone orders can be placed between 9am and 5pm Monday to Friday on our toll free number 1800 67 3383 or (02) 6201 9414.
Email us at aas@science.org.au.

I would like [__] copies of 'A building in the round' (VHS format video of Jack Deeble interview) @ $65.50 per copy.

Name:___________________________________________________

Address:_________________________________________________

_________________________________________________________

_____________________________________Postcode:___________

Order no. (if required):_______________

Please tick the appropriate box:

[__] Cheque enclosed [__] Charge our Academy account

[__] Bankcard [__] Mastercard [__] Visa

[__][__][__][__] [__][__][__][__] [__][__][__][__] [__][__][__][__]

Cardholder's name:__________________________________

Expiry date:___________Signature:____________________

Date:____________