THE AMERICAN SURGEON 2007
This is your form and/or invoice. All information must be completed or it will be returned.  Purchase Orders are not
accepted.  Please keep a copy of this document for your records.  ALL ORDERS AND PREPAYMENTS
MUST BE SENT TO ATLANTA.  NO PURCHASE ORDERS WILL BE ACCEPTED.

PLEASE PRINT OR TYPE ALL INFORMATION.

Author Name:                                                                                                                                                                                

Title of Article:                                                                                                                                                                              

                                                                                                                                                                                                        

Issue of Journal: Vol ______ Issue ______    Publication Date: ________ / ________    No. of Pages: _______ 
ORDER COSTS

_____ Number of reprints ordered                 $               

Add Color fee and/or shipping charges        $               

Taxes (if applicable)                                          $              

TOTAL                                                                $             

PAYMENT INFORMATION

Name                                                                                       

Institution                                                                              

Street                                                                                      

City                                                                                          

Country                                                                                  

       MC          Visa         AmEx   Exp. Date                         

Card No.                                                                                

Security Code.  _____________________________

Name on Card                                                                      

Signature                                                                              
Signature is required for all orders. By signing this form, the purchaser agrees to accept responsibility for the payment of all charges described in this document.

 SHIPPING ADDRESS

Attn:                                                                                              

Institution                                                                                    

Street                                                                                            

City                                               State                 Zip                

Phone Number                                                                           

SPECIAL INSTRUCTIONS

                                                                                                       

                                                                                                       

                                                                                                      

NO PURCHASE ORDERS WILL BE ACCEPTED

Prepayment by check or credit card in US Dollars, is required to process your order. You may use this form as your invoice.  To avoid delay, please FAX this form with your credit card payment to:

THE AMERICAN SURGEON
The Southeastern Surgical Congress
141 West Wieuca Road, B100
Atlanta, GA  30342

 

For more information, please call:
800/558-8958 or 404/255-4549
FAX: 404/255-5442

 

 

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