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)
