Ordered by
Name_______________________________________________________________________ Credentials_______________
Title_________________________________________________________________________________________________
Organization_______________________________________________ Department________________________________
Address_______________________________________________________________________________________________
City_________________________________________________________ State _________ ZIP ____________________
Phone: Office_______________________________________ Fax___________________________________________
E-mail Address_________________________________________________________________________________________
Ship to (if different than "ordered by")
Name_______________________________________________________________________ Credentials_______________
Title_________________________________________________________________________________________________
Organization_______________________________________________ Department________________________________
Address_______________________________________________________________________________________________
City_________________________________________________________ State _________ ZIP ____________________
Phone: Office_______________________________________ Fax___________________________________________
E-mail Address_________________________________________________________________________________________
Publication Number |
Free Copies |
Paid Copies |
Total Copies |
Price Each |
Total Cost |
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To order by phone:
800-358-9295 (toll free)
To order by E-mail:
AHRQPubs@ahrq.hhs.gov
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Mail this form to:
AHRQ Publications Clearinghouse
PO Box 8547
Silver Spring, MD 20907-8547
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Subtotal |
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Discount (if applicable) |
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Total |
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Credit Card Type MasterCard__________________________ Visa________________________
Card Holder's Full Name_______________________________________________________________
Credit Card Number_____________________________________ Expiration Date_______________
Please Note
For larger quantities or Purchase Orders, please call AHRQ Clearinghouse at 800-358-9295. Charges may apply for bulk quantities and for delivery to addresses outside of the United States.
____ Yes! Please send me Research Activities each month.
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