EL PASO COUNTY MEDICAL SOCIETY
2013 PICTORIAL DIRECTORY ORDER FORM

MAIL the form to: EPCMS, 730 Citadel Drive East, #206,
Colorado Springs, CO  80909
OR
FAX this form to 719-591-5649

We want to order ________ extra copies of the directory

New Book for Members = $35  New Book for Non-Members = $60
Inserts Only for Members = $25  Inserts Only for Non-Members = $50

Add:  $6.00 postage & handling for the first two directories ordered

Two or more directories must be picked up at the society office.

Payment must be received, in our office, before your order can be mailed.
Please print name and correct information below:

Name: ______________________________________________________________

Address directories will be mailed to: ______________________________________

Phone: _____________________________

Directory(s) #: _______________ @ $_______ = $________________
Plus Shipping and Handling Amount:       $________________
                                                            Total Due = $________________
(Sample:  2 directories @ $35 = $70 + $6.00 postage = $76.00)
Bill this credit card: 0  Visa  0  MasterCard
For: _____________ directories x ____________ = Total $ _________________________

________- ________ - ________ -________    _____________
          Credit Card Number                          Expiration Date

__________________________________________________________________
(Signature required for credit card payment)

__________________________________________________________________
(Address associated with credit card)

__________________________________________________________________
(Print Name as shown on credit card)
 

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