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.T.Services Order Form - Microsoft Internet Explorer

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Address http://www.clinicalpearls.com/scrip.htm

Ho w to use tliis fonn:

Ifyou have a standard,fax: print form, completeform, andfax to [phone]

Ifyou have a fax modem: save thisform as text, complete form in a text editor; andfax to [phone] Ifyou would like to pay by check or money order: print form, complete form, and mail to:

!TServices, 3301 AUaArden, Suitę 2, Sacramento, CA 95825 USA

Name:

Company:_

Email:

Phone:

FAX:

Bankcard #_ Address:

jyisA ot mastercard orjy) Ex. Date_

Country:_

Would you prefer your subscription by: EMAIL

KEGULAR.MAIL

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