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Address Name: ____________________________ Address: ___________________________ Address 2: __________________________ City: ___________________ State: ___ Zip: _________ Phone # ____________________ Email:______________________

Quantity Product Price Total Price ___ Qi Gong Meditation Vol. I, Four Tones & Elightenment - CD $15 $_____ ___ Qi Gong Meditation Vol. II, Circulate Universal Qi & Buddha Mind - CD $15 $_____ ___ Dantian Meditation - CD $15 $_____ ___ Dantian Meditation - CASSETTE $12 $_____ ___ The Microcosmic Orbit and 12 Meridian Meditations - CD $15 $_____ ___ The Microcosmic Orbit and 12 Meridian Meditations - CASSETTE $12 $_____ ___ Qi Gong For Health - VIDEO $35 $_____ ___ Qi Gong For Health - DVD $40 $_____ ___ Adult T-Shirt (Not Women's): Indicate Size and Color: _______ $15 $_____ ___ Women's T-Shirt: Indicate Size, V-neck or Crew, and Color: _______ $15 $_____   SHIPPING/HANDLING = $5 first item, $1 per additional items S/H $_____   TOTAL $_____

• Please print and fill out
• Please make check or money order payable to Lisa B. O'Shea
• Please mail to:
  Qi Gong Institute
  595 Blossom Road Suite 307
  Rochester, NY 14610