Neuropathology Illustrated 2.0 CD-ROM - Site License Order Form

     Your Institution:  ________________________________________

     Contact Person: ___________________________________________

     Your Address:   ___________________________________________

                     ___________________________________________

                     ___________________________________________

                     ___________________________________________

                     ___________________________________________

     E-mail address: ___________________________________________

     Telephone:      __________________  Fax: __________________

Ordering:

     Number of site licenses   ______  X $300.00 each = $ __________

     Shipping and Handling cost (see below)             $ __________

     Upgrade from prior version for $60 each =          $ __________

     Total                                              $ __________

Shipping and Handling Costs:

     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:

Neuropathology Illustrated

Department of Pathology 5C-124

50 North Medical Drive

Salt Lake City UT 84132 USA

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