Order Form_PD2_FCPIs Form PD2 FCPIs
User Manual: OrderForm_PD2_FCPIs
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ENGLISH CREIGHTON MODEL FertilityCare TM INTERN PUBLICATIONS ORDER FORM Order Date Intern’s Name Phone # Fax # Supervisor’s Name Intern’s Email Purchase Order# BILL TO: Name SHIP TO: Name c/o c/o Address Address City/State Zip City/State Zip QUANTITY Signature required on Page 2 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-2) 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** 9/28/12va Prices Subject to Change Shipping and Handling and Taxes, if applicable, will be added to the invoice. The billing Invoice will be mailed and/or emailed to the intern for payment. Select Payment: PayPal to account: publications@popepaulvi.com Credit Card Number: ______________________________________________ Expiration Date: __________________________________________________ Name on card: (please print)__________________________________________ Signature of Intern: _______________________________________________________ Signature of Supervisor: ___________________________________________________ (Required on all Intern Orders) Email of Supervisor: ______________________________________________________ IMPORTANT: Once the order is complete and signed by the supervisor, send the order by email to: publications@popepaulvi.com (Pope Paul VI Institute’s Publications Department) or fax it to 402-3909851 for final review. No orders are to be sent directly to the licensed language representative. **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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