Q1 2015 Product Catlog Anniversary Specials - page 11

RENEW YOUR MEMBERSHIP TO RECEIVE MEMBER PRICING
Please check one:

Nonmember

Individual or Center Member
Name:_____________________________________________________________________
Member Number: _ __________________________________ Date: _ _____________
BILL TO NAME:
_ _________________________________________________________________________________________
Address:____________________________________________________________________________________________________
City: _ ________________________________________________ State:_______________ Zip Code:______________________
Phone: _______________________________________________ Fax:__________________________________________________

Residential

Commercial
SHIP TO NAME:
__________________________________________________________________________________________
Address:____________________________________________________________________________________________________
City:__________________________________________________ State:_______________ Zip Code:______________________
Phone:_ ______________________________________________ Fax:__________________________________________________
Email:_ _____________________________________________________________________________________________________

Check (U.S. Bank Only)

Purchase order No.: ____________________________________________________
($500.00 Minimum on all Purchase Orders. Hard copy of the PO must be attached.)

Visa

MasterCard

American Express
Credit Card Number:_______________________________________________________________________________________
Expiration Date:_ _______________ Verification Code: ___________
Credit Card Billing Address:_________________________________________________________________________________
City:__________________________________________________ State:_______________ Zip Code:______________________
SHIPPING FOR US GROUND ORDERS ONLY
PRODUCTS
ORDERED
IL, IN, MI,
WI
IA, KY, MN,
MO, OH, TN,
WV
AL, AR, DE, GA, KS, MD, MS,
NC, ND, NJ, NY, OK, PA, SC,
SD, VA, VT
CO, CT, FL, LA,
MA, ME, NH,
RI, TX
AZ, CA, ID, MT,
NM, NV, OR, UT,
WA, WY
1-3 Items
$13
$13
$13
$13
$14
4-6 Items
$13
$14
$15
$17
$20
7-12 Items
$18
$19
$22
$27
$33
13-18 Items
$22
$24
$28
$34
$41
19-24 Items
$30
$33
$38
$48
$55
All Alaska, Hawaii and Non - U.S. orders will be based on cost.

Next Day Based on Cost

Second Day Based on Cost
AMERICAN ACADEMY OF SLEEP MEDICINE
PRODUCT ORDER FORM
1...,2,3,4,5,6,7,8,9,10 12
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