Peter Kwok's Kung Fu Academy

CHIN NA Video Tape Order Form

Please print this form and mail it with your payment to the address below.

To Order and receive a 20% Off
The Remaining Purchase of 5 ChinNa Video Tapes

SEND Check or Money Order for $29.95
( for EACH CHIN NA 2-Man Form Vol 1 tape)

Payable to : Peter Kwok's Kung Fu Academy
207 Kinderkamack Road
Emerson, New Jersey 07630

Or Phone in your order:
Call Randy at (201) 967-0790

*Please Note: If you cannot print out the application form, you may submit the information on a seperate sheet of paper.
Last Name: __________________________________________
First Name: __________________________________________
Current Address:_______________________________________
City:________________ State:______________ Zip:__________
E-Mail Address:________________________________________
Home Tel#:_______________ Work Tel#:___________________
Date:_________________________________________________
Applicant's Signature:___________________________________
*Note: Orders with a Money Order, Certified Check or Cash will be sent out immediately. If a personal check is sent, we will hold your order until your check clears.

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