Educational Materials Order Form
Print out, complete this form and return to:
Rehabilitation Institute of Chicago
Education and Training Dissemination
345 East Superior Street, Suite 1671
Chicago, Illinois 60611
Or, you may return this form via FAX: (312) 238-4451
If you prefer to pay by credit card, you may call (312) 238-2859, or complete:
Indicate type of card: Visa [ ] MasterCard [ ]
_______________________________ ____________________
Credit Card Number Exp. Date
__________________________________________________
Signature
Quantity Price
1-50 30 cents each
51-100 25 cents each
over 100 20 cents each
Place a check in the box next to the publication(s) you wish to order:
Publication Quantity x Price per item = Total
[ ] Coping Following Stroke ___ ___ ______
[ ] Adaptiación Después de un Derrame Cerebral o Apoplejía ___ ___ ______
[ ] Nutrition ___ ___ ______
[ ] Nutricion ___ ___ ______
[ ] Sex After Stroke ___ ___ ______
[ ] Sexo Después de un Derrame Cerebral ___ ___ ______
[ ] Spirituality ___ ___ ______
[ ] Espiritualidad ___ ___ ______
[ ] Driving Following a Stroke ___ ___ ______
[ ] Manejar Después de un Derrame Cerebral o Apoplejía ___ ___ ______
[ ] Return to Work Following a Stroke ___ ___ ______
[ ] Regreso al Trabajo Después de un Derrame Cerebral o Apoplejía ___ ___ ______
TOTAL ______
All prices and fees are in US dollars.
Make check or money order payable to:
Rehabilitation Institute of Chicago
Your Billing Address:
Organization _________________________________________________________
Name _______________________________ Title _________________________
Address ______________________________________________________________
City ________________________________ State _________ Zip ___________
Phone Number _________________________________________________________
Shipping Address:
Organization _________________________________________________________
Name _______________________________ Title _________________________
Address ______________________________________________________________
City ________________________________ State _________ Zip ___________
Phone Number _________________________________________________________