AHRQ Publications Order Form

Ordered by

Name __________________________________________________________________________________

Credentials __________________

Title____________________________________________________________________________________

Organization______________________________________________________________________________

Department _____________________________________________________________________________

Address ________________________________________________________________________________

City____________________________________________________________________________________

State _____________________ Zip _______________

Office Phone_____________________________________________________________________________

Fax___________________________________________________________________________________

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Ship to (if different than "ordered by")

Name __________________________________________________________________________________

Credentials __________________

Title____________________________________________________________________________________

Organization______________________________________________________________________________

Department _____________________________________________________________________________

Address ________________________________________________________________________________

City____________________________________________________________________________________

State _____________________ Zip _______________

Office Phone_____________________________________________________________________________

Fax___________________________________________________________________________________

Email Address____________________________________________________________________________

 

Publication NumberFree CopiesPaid CopiesTotal CopiesPrice EachTotal Cost
      
      
      
      
      
      
      
      
      

To order by phone:
800-358-9295 (toll free)

To order by email:
AHRQPubs@ahrq.hhs.gov

Mail this form to:
AHRQ Publications Clearinghouse
PO Box 8547
Silver Spring, MD 20907-8547

Subtotal 
Discount
(if applicable)
 
Total 

Credit Card

Credit Card Type     ____MasterCard      ____Visa

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Expiration Date___________________________________________________________________________

Please Note

For larger quantities or Purchase Orders, please call the AHRQ Clearinghouse at 800-358-9295. Charges may apply for bulk quantities and for delivery to addresses outside of the United States.

____ Yes! Please send me Research Activities each month.

Current as of April 2012
Internet Citation: AHRQ Publications Order Form. April 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/publications/order/order-form.html