PIntern Price List Order Form PD 2
User Manual: PIntern-Price-List-Order-form-PD-2
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CREIGHTON MODEL FertilityCare™
INTERN PUBLICATIONS ORDER FORM (PD-2)
Continued on page 2
Order Date
Supervisor’s
Name
Signature required on Page 2
Intern’s Name
Intern’s Email
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
INTERN: English
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
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**
