Q4 2014 Quarterly Product Catalog - page 11

11
Please check one:
ï‚£
Nonmember
ï‚£
Individual or Center Member
Name:___________________________________________________________
Member Number: _____________________ Date: _______________________
Bill to Name:
_ __________________________________________________________________________________
Address: _ ______________________________________________________________________________________
City:_________________________________ State: _ _____________________ Zip Code:_______________________
Phone:_ ____________________________________________ Fax: ________________________________________
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Residential
ï‚£
Commercial
Ship to Name:
___________________________________________________________________________________
Address: _ ______________________________________________________________________________________
City:_________________________________ State: _ _____________________ Zip Code:_______________________
Phone:_ ____________________________________________ Fax: ________________________________________
Email: __________________________________________________________________________________________
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Check (U.S. Bank Only)
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Purchase Order No.: _ ____________________________________________________
($500.00 Minimum on all Purchase Orders. Hard Copy of the PO must be attached)
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ï‚£
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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.
ï‚£
Next Day Based on Cost
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Second Day Based on Cost
American Academy of Sleep Medicine
PRODUCT ORDER FORM
1...,2,3,4,5,6,7,8,9,10
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