 |
Fax to: The Marketing Research Bureau Inc.
Fax: +1 203 891-8855
ORDER FORM Opportunity Assessment of Three Leading Investigational PRICE & DELIVERY $1,750. Shipment will be made by priority mail within the U.S. upon receipt of the order or payment, and by airmail for international orders. |
|
|
 |
Please send the Directory by overnight courier (add $20.00 for domestic |
 |
shipment $45.00 for international) | |
|
PAYMENT : | |
|
|
PAYMENT FOLLOWS BY CHECK in US dollars, issued on a U.S. Bank or U.S. correspondent bank or by WIRE TRANSFER to Bank of America, Orange, Connecticut 06477,USA, Account number 007103 7303, routing number 0260-0959-3. Swift code: BOFAUS3N |
|
|
BY ENCLOSED CHECK in US dollars, issued on a U.S. Bank or U.S. correspondent bank |
|
|
PLEASE BILL ME Purchase order Number (optional)________________________________ |
|
BY
CREDIT CARD |
Visa
/ Mastercard / Eurocard |
American
Express |
|
Card Number ____________________________________________________________ |
|
Expiration date __________________________________________________________ |
|
Signature________________________________________________________________ |
|
Please print your name___________________________________________________ |
|
REPORT TO BE SENT TO: Name ____________________________________________ Title _____________________________________________ Company _________________________________________ Address __________________________________________ City/Postal Code___________________________________ Country ___________________________________________ Telephone _______________ Fax: ____________________
|