AHRQ Publications Order Form
Ordered by
Name __________________________________________________________________________________
Credentials __________________
Title____________________________________________________________________________________
Organization______________________________________________________________________________
Department _____________________________________________________________________________
Address ________________________________________________________________________________
City____________________________________________________________________________________
State _____________________ Zip _______________
Office Phone_____________________________________________________________________________
Fax___________________________________________________________________________________
Email Address____________________________________________________________________________
Ship to (if different than "ordered by")
Name __________________________________________________________________________________
Credentials __________________
Title____________________________________________________________________________________
Organization______________________________________________________________________________
Department _____________________________________________________________________________
Address ________________________________________________________________________________
City____________________________________________________________________________________
State _____________________ Zip _______________
Office Phone_____________________________________________________________________________
Fax___________________________________________________________________________________
Email Address____________________________________________________________________________
Publication Number | Free Copies | Paid Copies | Total Copies | Price Each | Total Cost |
---|---|---|---|---|---|
To order by phone: To order by email: | Mail this form to: | Subtotal | |||
Discount (if applicable) | |||||
Total |
Credit Card
Credit Card Type ____MasterCard ____Visa
Card Holder's Full Name____________________________________________________________________
Credit Card Number_______________________________________________________________________
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.