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Please send a free copy of "Party 101: Consequences"

* What is your intended use of the program? (i.e. who will view the documentary, will it be a group or organization)

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* Please mark any choices that may apply to you.

* Are you a member of the Parent Teachers Association?

No	Yes, My local unit is

* Are you a member of the Independent Insurance Agents of Texas?

No	Yes, My agency is

Shipping Information:

All DVDs will be shipped via US Postal Service and only to a Texas address. You should receive your copy of "Party 101: Consequences" within 1-2 weeks. Please call 1-800-TALK-PTA if you need expedited shipping. There will be a fee for any express delivery services.

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* Indicates Response Required

Parent or Guardian	Student	Educator or Counselor
School Administrator	Government or Law Enforcement Official	Civic Organization