PIntern Price List Order Form PD 2
User Manual: PIntern-Price-List-Order-form-PD-2
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INTERN: English CREIGHTON MODEL FertilityCare™ INTERN PUBLICATIONS ORDER FORM (PD-2) Supervisor’s Name Order Date Intern’s Name Intern’s Email Phone # Fax # Purchase Order# BILL TO: Name c/o Address SHIP TO: Name c/o Address City/State/Zip City/State/Zip QUANTITY Signature required on Page 2 ITEM PACKAGE PRICE Each Package of 25 Each Each Package of 25 Each $1.50 $32.50 $10.00 $3.50 $81.25 $1.50 Pregnancy Eval. — long Introductory Session PowerPoint on CD General Intake Forms Each $2.00 $95.00 Package of 25 $13.50 Information Cards Package of 25 $12.00 Organizer Sheets Spice Index Cards Telephone Pads Introductory Session Evaluation Pad of 25 Package of 25 Pad of 25 Pad of 25 $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 Yellow Stamp Instructions Set Pad of 25 $7.00 Pad of 25 $7.00 Charts User Manuals Follow-up Forms Pregnancy Eval. — short Individual YS Topic Package Topic Name:_____________________ Picture Dictionary: Teacher Edition Picture Dictionary: User Edition Each Each Set=1 each of 7 topics 25 sheets of one topic 1-4 ordered 5-9 ordered 10+ ordered 1 TOTAL (Non returnable item) $.35 $3.00 $9.50 $54.98 each $49.98 each $44.98 each $20.00 Continued on page 2 QUANTITY ITEM PACKAGE 1 Stamp Starter Pack Protective Plastic Plain Red Stamp White Baby Stamps Plain Green Stamps Green Baby Stamps Plain Yellow Stamps Yellow Baby Stamps 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 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: __________________________________________________________ Exp. Date: _____________ Name on card (please print) ____________________________________________ Zip Code of card: _______________________ Signature of Card Holder: ______________________________________________________________________________________ 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 for approval by email to: publications@popepaulvi.com (Pope Paul VI Institute’s Publications Department) or fax it to (402) 390-9851. **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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