Jacobs Institute of Women's Health
Publications Order Form

Please print out the following form, fill out and mail or fax to the following address:

Jacobs Institute of Women's Health
409 12th Street, SW
Washington, DC  20024-2188

Phone: 202-863-4990

Fax: 202-488-4229

Name and Title: _______________________________________
Organization: _______________________________________
Street Address : _______________________________________
City _______________________________________
State/Zip: _____________________
Phone (area code first): ( ___ ) ____ - _________
Fax (area code first): ( ___ ) ____ - _________
E-mail address ______________ @ _____________________

  Please send me the following information (free of charge):   

/   / Information about the Jacobs Institute
/   / Jacobs Ortho-McNeil Scholar Research Award Information  
/   / Internship Opportunities
/   / Other _________________________________

  Please send me the following items:

Item 

Qty. Price  Total
  Regular Membership   _____   $55.00   $__________
  Guidelines for Counseling
  Women on the Management
  of Menopause
  $7.50
  Womens Health and
  Managed Care:
  Opportunities for Action
  $15.00
  State Profiles   _____   $30.00   $__________
 Women's Health Data Book 2nd Edition   _____   $28.95   $__________
 Women's Health Data Book 3rd Edition   _____   $33.00   $__________
  Women's Health Issues
(specify volume and issue no.)
  _____   $21.50   $__________
  Insights   _____   $25.00   $__________
 Value Purchasing:  Investing in Women's Health - Strategies for Employers   _____   $15.00   $__________
  _________________________   _____   $__________   $__________
  _________________________   _____   $__________   $__________

Shipping charges:  

# of Items Shipping Charge

1-2

$3.50

3-9

$6.50

10-20

$10.00

Shipping: 

  $__________

Total Amount Due: 

  $__________

Please enroll me as a member of the Jacobs Institute.
(For details on membership, click here
.)
Please select one:

 /  / Regular ($55) /  / Contributor ($100)  /  / Supporter ($250)
 /  / Institutional ($250) /  / Corporate ($1,000)

Payment Method:

/  / Check (mail to address below) or

/  / VISA/MasterCard (please circle selection)

Account Number  ______ - ______ - ______- ______ Expiration Date __ / ____

Cardholder's name ___________________________

Note: Members may take a 20% discount on publications, audio tapes and resource packets. Invoicing available for orders of 10 or more only.

WE DO NOT ACCEPT RETURNS.
PAYMENT MUST BE RECEIVED PRIOR TO SHIPPING.

Help the Institute continue to provide acclaimed programs, projects, and publications by making a tax-deductible donation toward its effort of advancing the knowledge, practice and understanding of women's health.  Total amount enclosed: $ _____________  

 

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