Virtual Reality Aids, Inc. Offline Order Form  
 Order Summary
       Product Name
Price  
Quantity
Total      
   $    $
   $    $
   $    $
   $    $
   Subtotal:
$0.00 

Friday, August 29, 2008, 6:20pm EDT
Total:
$0.00 
   Billing Address:  
Name  
Company Name  
Address  
City  
State/Province  
Country  
Zip  
Phone  
E-mail*  
*REQUIRED - your email address will be used as your login ID
  Shipping Information:
 Shipping & Billing address are the same
Name  
Address  
City  
State/Province  
Zip  
  Payment Information:
 (circle one) Check, Money Order, Visa, MasterCard

If Visa or MasterCard:
Card Number:
  
Expiration:
  
Cardholder's
Signature:
  

Or phone in order to:  (919) 755-1809
M-F 9:00am - 3:00pm EST

  Print this form, fill in your address and payment information and send the completed form with applicable payment to us by:
   Fax:  (919) 420-1978
            USA
   Mail: Do2Learn
             3204 Churchill Road
             Raleigh, NC 27607
             USA
   Please make Check payable to:
              Virtual Reality Aids, Inc.