Order Form_PD1_FCPs Form PD1 FCPs
User Manual: OrderForm_PD1_FCPs
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CREIGHTON MODEL FertilityCareTM PRACTITIONER PUBLICATIONS ORDER FORM Order Date Name Phone # Fax # FCCA Center Name FCCA Center # Purchase Order# BILL TO: Name SHIP TO: Name c/o c/o Address Address City/State Zip City/State Zip QUANTITY ITEM PACKAGE PRICE Charts Each Package of 25 $ 1.50 $32.50 Spanish Charts Each Package of 25 Each Each Each Package of 25 $ 1.50 $32.50 $ 10.00 $10.00 $ 3.50 $81.25 Pregnancy Eval. - short Pregnancy Eval. - long Introductory Session Power Point on CD General Intake Forms Information Cards Organizer Sheets Spice Index Cards Telephone Pads Each Each Each (Circle MAC or PC) Package of 25 Package of 25 Pad of 25 Package of 25 Pad of 25 $ 1.50 $ 2.00 $95.00 Introductory Session Evaluation Follow-up Evaluation Teacher Evaluation Reproductive Category Spec. Cycle Review Census Form Yellow Stamp Instructions Set Pad of 25 Pad of 25 Pad of 25 Pad of 25 $7.00 $7.00 $7.00 $7.00 Each Set=1 each of 7 topics 25 sheets of one topic $ .35 $3.00 User Manuals Spanish User Manuals Follow-up Forms Individual YS Topic Package Topic Name:_____________________ (Non returnable item) $13.50 $12.00 $ 5.50 $13.50 $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 $20.00 Order continues on Page 2 … 1 (PD-1) EXTENDED PRICE QUANTITY ITEM 1 Stamp Starter Packs Protective Plastic Plain Red Stamp White Baby Stamps Plain Green Stamps Green Baby Stamps Plain Yellow Stamps Yellow Baby Stamps PACKAGE PRICE 11 sheets + bag 1 bag Per sheet Per sheet Per sheet Per sheet Per sheet Per sheet $2.50 EXTENDED PRICE $0.30 $0.25 $0.25 $0.25 $0.25 $0.25 $0.25 Additional Products: TOTAL FOR MATERIALS ORDERED** 4/8/14st 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: _______________________________________________ Expiration Date: ____________________________ Name on card (please print) __________________________________________ Signature of Practitioner: ___________________________________________________ **ALL International orders will be required to pre-pay their invoices before shipping by credit card or PayPal to account: publications@popepaulvi.com. As of January 1, 2013, all domestic orders will be required to pre-pay before shipment. In order to be on a billing program, affiliated FCCA centers and Educators will be required to sign a payment contract with Pope Paul VI Institute. Return to: Pope Paul Vi Institute 6901 Mercy Road Omaha, NE 68106 Publications Email: publications@popepaulvi.com Phone: 402-505-8942 FAX: 402-390-9851
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