Affiliate Price List Order Form PD 1
User Manual: Affiliate-Price-List-Order-form-PD-1
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AFFILIATE: English CREIGHTON MODEL FertilityCare™ AFFILIATE PUBLICATIONS ORDER FORM (PD-1) FCCA Center Name FCCA Center # Order Date Responsible Practitioner Phone # Purchase Order# Fax # BILL TO: SHIP TO: Name Name c/o c/o Address Address City/State/Zip City/State/Zip QUANTITY ITEM Charts User Manuals Follow-up Forms Pregnancy Eval. — short Pregnancy Eval. — long Introductory Session PowerPoint on CD General Intake Forms Information Cards Organizer Sheets Spice Index Cards Telephone Pads Introductory Session Evaluation PACKAGE PRICE Each Package of 25 Each Each Package of 25 Each Each $1.50 $32.50 $10.00 $3.50 $81.25 $1.50 $2.00 Each Package of 25 Package of 25 Pad of 25 Package of 25 Pad of 25 Pad of 25 $95.00 (Non returnable item) $13.50 $12.00 $5.50 $13.50 $3.00 $7.00 Follow-up Evaluation Pad of 25 $7.00 Teacher Evaluation Reproductive Category Spec. Cycle Review Census Form Pad of 25 $7.00 Pad of 25 $7.00 Yellow Stamp Instructions Set Set: 1 each of 7 topics $3.00 Individual YS Topic Package 25 sheets of one topic 1-4 ordered 5-9 ordered 10+ordered 1 $9.50 Topic Name: _________________________ Picture Dictionary: Teacher Edition Picture Dictionary: User Edition Each TOTAL $.35 $54.98 each $49.98 each $44.98 each $20.00 Order continues on Page 2 … QUANTITY ITEM 1 Stamp Starter Pack Protective Plastic Plain Red Stamp White Baby Stamps Plain Green Stamps Green Baby Stamps Plain Yellow Stamps Yellow Baby Stamps PACKAGE 11 sheets + bag 1 bag Per sheet Per sheet Per sheet Per sheet Per sheet Per sheet PRICE TOTAL $2.50 $0.30 $0.25 $0.25 $0.25 $0.25 $0.25 $0.25 Additional Products: TOTAL FOR MATERIALS ORDERED** 6/1/14smt Prices Subject to Change Shipping and Handling, Discounts, Taxes, if applicable, will be applied. All orders must be pre-paid before shipping. Estimate can be sent by email if paying by check. Email address: __________________________________________________________________________________ Select Payment: PayPal to account: publications@popepaulvi.com Credit Card Number: __________________________________________________________ Exp. Date: __________ Name on card (please print) ____________________________________________ Zip Code of card: ____________________ Signature of Card Holder: ___________________________________________________________________________________ Signature of Responsible Practitioner: _________________________________________________________________________ **ALL international orders will be required to pre-pay their invoices before shipping by credit card or PayPal to account: publications@popepaulvi.com. All domestic orders will be required to pre-pay before shipment. Return to: Pope Paul VI Institute, 6901 Mercy Rd., Omaha, NE 68106 Publications Email: publications@popepaulvi.com Phone: (402) 505-8942 FAX: (402) 505-8908
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