PHYSICIAN CONTACT INFORMATION

*Physician:
Company:
Hospital:
Your Title:
Department:
*Street Address:	Suite:
*City:
*State:	Country:
*Zip Code:
*Day Telephone:	Ext:
Service Number:
Fax:
*E-Mail Address:
Web Address:
PROFESSIONAL INFORMATION
*Specialty:
*Clinical Interests:
*Medical Education:
*Residency:
Certifications:
Awards:
Achievements:
Publications:
Geographic Preference:	Make Selection: Northeast: New England Northeast: Mid Atlantic Midwest: East North Central Midwest: West North Central South: South Atlantic South: East South Central South: West South Central West: Mountain West: Pacific
PHYSICIAN PHOTOGRAPHY INFORMATION
*Physician Photograph:	Make Selection: Will Mail Professional Headshot Will EMail .Tiff Headshot Photography Needed. Please Contact
CUSTOM BOOK LABEL INFORMATION
*Line #1 Text:
*Line #2 Text:
*Line #3 Text:
BOOK ORDERING INFORMATION
Yes or No:	I am ordering 500 copies of the book “16 Things ...” along with my 500 custom labels for the discounted price of $8.95 per book. (Over 40% Off $14.95 Retail Price)
Yes or No:	I am ordering 1,000 copies of the book “16 Things ...” along with my 1000 custom labels for the discounted price of $7.45 per book. (Over 50% Off $14.95 Retail Price)
Yes or No:	I am sending in a 10% deposit check to reserve my books
Yes or No:	Please bill me at my above address
Yes or No:	I prefer to pay now by credit card over a secure connection
Yes or No:	I agree to add the “16 Things...” book info and link on my website or homepage
Yes or No:	Terms and Conditions: I agree with the terms and conditions herein set forth

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