CD-ROM ORDER FORM
Internet 101:
Please print, complete, and mail this form to address
shown below.
| Name: |
| If you are an AAPS member, please enter member number: |
| Organization: |
| Address: |
| City-State-Zip: |
| Daytime phone: |
| FAX number: |
| E-mail address (print very clearly): |
Purchase Fees:
| Product: | Members: | Nonmembers: |
| CD-ROM: INTERNET 101 | $60 | $90 |
| 4 1/2% Sales Tax for VIRGINIA Residents Only | $2.70 | $4.05 |
Total amount submitted: ________
| Payment by check: | [ ] Check (Check Number _____________ Payable to AAPS in U.S. dollars, drawn on a U.S. bank. |
| Please charge my: | [ ] Visa | [ ] MasterCard | [ ] American Express | [ ] Discover |
| Card Number: | Expiration Date: |
| Cardholder Name (Print) | Auth. Signature:
|
| AAPS cannot accept purchase orders |
|