To: The Marketing Research Bureau Inc.
284 Racebrook Road
Orange, CT 06477, USA
Phone +1 203 799-0298 Fax: +1 203 891-8855
ORDER FORMINTERNATIONAL BLOOD/PLASMA NEWS ON COMPACT DISK
Price
$495.00 (Four hundred and ninety five dollars). Overnight delivery shipment: $25 domestic, $50 International.
Payment (please check as many as required)
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 003850938248, routing number & swift code available upon request.
Card Number: ________________________________________ Expiration date: __________
Signature: __________________________________________________________________
Please print name: __________________________________________________________
CD to be sent to:
Name:____________________________________________________
Title:_____________________________________________________Company:_________________________________________________
Address:__________________________________________________
_________________________________________________________
City & Postal Code:__________________________________________
Country:___________________________________________________
Telephone:__________________Fax:____________________________
E-Mail:____________________________ Date:____________________