Order Form_PD2_FCPIs Form PD2 FCPIs
User Manual: OrderForm_PD2_FCPIs
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CREIGHTON MODEL FertilityCareTM
INTERN PUBLICATIONS ORDER FORM (PD-2)
Order continues on Page 2 …
Order
Date
Supervisor’s
Name
Signature required on Page 2
Intern’s
Name
Intern’s
Email
Phone #
Fax #
Purchase
Order#
BILL TO:
SHIP TO:
Name
Name
c/o
c/o
Address
Address
City/State
Zip
City/State
Zip
QUANTITY
ITEM
PACKAGE
PRICE
EXTENDED PRICE
Charts
Each
Package of 25
$ 1.50
$ 32.50
Spanish Charts
Each
Package of 25
$ 1.50
$ 32.50
User Manuals
Each
$ 10.00
Spanish 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
Power Point on CD
Each (Circle
MAC or PC)
$ 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
ENGLISH
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 402-390-
9851 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
QUANTITY
ITEM
PACKAGE
PRICE
EXTENDED PRICE
1 Stamp Starter Packs
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**
