Return to the CD-ROM menu.
Your Name: ___________________________________________
Your Address: ___________________________________________
___________________________________________
___________________________________________
E-mail address: ___________________________________________
Telephone: __________________ Fax: __________________
Number of CD-ROM's ordered _____ for $50.00 each = $ __________
Upgrade from prior version for $10 each = $ __________
Shipping and Handling cost (see below) $ __________
Total $ __________
To addresses in the U.S., Canada, and Mexico:
Regular Airmail - $3.00 Express Mail - $10.00
Overnight Mail - $20.00
To other foreign addresses: Foreign Airmail - $10.00
Make checks, money orders, or purchase orders (in U.S. dollars) payable to: Department of Pathology
Method of Payment (circle one):
Check Money Order Purchase Order # _______________________________
Name and Address ______________________________________________________
of Cardholder
(if different from ______________________________________________________
above - please print)
______________________________________________________
Visa MasterCard Card # _________________________________________
Signature ________________________________________ Expiration ____________
Either fax this form with credit card information to 801-581-2921 or mail the completed form (with credit card information or payment) to the following address: