Affiliate Price List Order Form PD 1

User Manual: Affiliate-Price-List-Order-form-PD-1

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CREIGHTON MODEL FertilityCare™
AFFILIATE PUBLICATIONS ORDER FORM (PD-1)
Order continues on Page 2 …
Order Date
FCCA Center
Name
Responsible
Practitioner
FCCA
Center #
Phone #
Purchase
Order#
Fax #
BILL TO:
SHIP TO:
Name
Name
c/o
c/o
Address
Address
City/State/Zip
City/State/Zip
QUANTITY
ITEM
PACKAGE
PRICE
TOTAL
Charts
Each
Package of 25
$1.50
$32.50
User Manuals
Each
$10.00
Follow-up Forms
Each
Package of 25
$3.50
$81.25
Pregnancy Eval. — short
Each
$1.50
Pregnancy Eval. — long
Each
$2.00
Introductory Session
PowerPoint on CD
Each
$95.00
(Non returnable item)
General Intake Forms
Package of 25
$13.50
Information Cards
Package of 25
$12.00
Organizer Sheets
Pad of 25
$5.50
Spice Index Cards
Package of 25
$13.50
Telephone Pads
Pad of 25
$3.00
Introductory Session Evaluation
Pad of 25
$7.00
Follow-up Evaluation
Pad of 25
$7.00
Teacher Evaluation
Pad of 25
$7.00
Reproductive Category
Spec. Cycle Review
Pad of 25
$7.00
Census Form
Each
$.35
Yellow Stamp Instructions Set
Individual YS Topic Package
Topic Name: _________________________
Set: 1 each of
7 topics
25 sheets of
one topic
$3.00
$9.50
Picture Dictionary: Teacher Edition
1-4 ordered
5-9 ordered
10+ordered
$54.98 each
$49.98 each
$44.98 each
Picture Dictionary: User Edition
1
$20.00
AFFILIATE: English
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
QUANTITY
ITEM
PACKAGE
PRICE
TOTAL
1 Stamp Starter Pack
11 sheets + bag
$2.50
Protective Plastic
1 bag
$0.30
Plain Red Stamp
Per sheet
$0.25
White Baby Stamps
Per sheet
$0.25
Plain Green Stamps
Per sheet
$0.25
Green Baby Stamps
Per sheet
$0.25
Plain Yellow Stamps
Per sheet
$0.25
Yellow Baby Stamps
Per sheet
$0.25
Additional
Products:
TOTAL FOR MATERIALS ORDERED**

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