NCPIE Resources Order Form
(Please print out and complete this two-page form.)
Catalog # Item Price Quantity Total:
#BMW-01 Be MedWise - Ask Me How! Button $7.50/pack of 10   $
#BMW-02 Use Over-the-Counter Medicines Wisely -
English Version		 $20/pack of 100   $
#BMW-03 Use Over-the-Counter Medicines Wisely -
Spanish Version		 $20/pack of 100   $
#B-21

Getting The Most From Your Medicines:
Managing Side Effects

 $15/pack of 100   $
#B-20 Alcohol and Medicine: Ask Before You Mix $10/pack of 100   $
Not a member? Click here for NCPIE
Membership Application
 Subtotal: $
NCPIE Members Deduct 20%: $
Add Shipping/Handling: $
Total: $

Shipping and Handling:
Most orders are shipped via UPS Ground; rush or international delivery requires an additional charge
    ­ call or email NCPIE for details.
If Order Totals Add:
  Less than $25   $8
  $25 -- $49.99   $11
  $50 -- $99.99   $16
  $100 - $149.99   $20
  $150 - $200.00   $23
  Above $200   Call for Quote
Name:
Title:
Organization:
Address:
City:
State/Zip:
Phone:
Fax:

Payment Information

NCPIE Federal Tax ID#:
52-1272884
     Signed institutional purchase order ($25 minimum). Please attach a copy
         of the purchase order to this form. PO# _______________
 
    Credit Card orders: (fax to (301) 340-3944)         Visa         Mastercard
Account Number:  
Exp. Date:  
    Check or Money Order (payable to NCPIE, in U.S. dollars only)
    If paying by check, please mail the form and your payment to:
NCPIE
200-A Monroe Street, Suite 212
Rockville, MD 20850-4448 		Phone: (301) 340-3940