Fax/Mail Order Form

Please print and use this form for FAX and Mail orders.

Customer Information:

Name:
Practice/Business:
Address 1:
Address 2:
City:
State/Region:
Zip/Postal Code:
Country:
Phone #:
FAX #:
eMail:

Products:

Product	Quantity	Price	Extended
2010 Behavioral Health MultiBook		@ $129.00	=
		@	=
		@	=
		@	=
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Subtotal:			=
UT State Tax* (Utah residents only)	Rate:	5.95%	=
Shipping: Ground (up to 6 lbs): $9.95, (7-12 lbs is $15.95); Call for heavier weights or faster shipping 877-963-2633			=
TOTAL:			=

* To calculate tax, multiply the Subtotal amount by .0595

Payment:

       Check/Money Order Enclosed (Mail Orders)

       Purchase Order #: (Please enclose or fax for our records.)

       Credit Card (circle one)   Amex   Discover   MC   Visa

Card #:

Exp. Date:

Name on Card:

Comments & Questions:

FAX or Mail this Form

FAX:	(877) 272-0780 (toll-free)
Mail:	InstaCode Institute 2314 West 8900 North Dammeron Valley UT 84783

Fax/Mail Order Form

Please print and use this form for FAX and Mail orders.

Customer Information:

Products:

Payment:

Comments & Questions:

FAX or Mail this Form

Thank you for your order!