Medical Directory Order Form Jola Publications

Jola Publications
Medical Directory Order Form
Contact Name ______________________________________________________ Purchase Order #________________
Company ________________________________________________________________________________________
Mailing Address __________________________________________________________________________________
Physical Address (if different from mailing address)_______________________________________________________
City _____________________________________ State ________________ ZIP ____________________________
Phone (REQUIRED)
(________) ____________________ Dept. __________________________
Email address is only used for shipment notification & receiving this flyer. We do not share with any third parties.
Email:_______________________________________________________________________________________
Qty.
State Medical Directory
Cost
Wisconsin (July 2014-2015)
$25
Minnesota (September 2013-2014)
$25
Minnesota (October 2014-2015) (Pre-Sale for publication date Oct. 2014)
$25
Iowa (January 2014-2015)
$25
Nebraska (March 2014-2015)
$25
North & South Dakota (April 2014)
$25
SHIPPING & HANDLING ADD
SUBTOTAL
Price Total
$6
Orders shipped within the state of Minnesota are subject to sales tax. The exact rate varies based on
your ZIP code. If you are unsure what tax rate you should be paying, please visit:
www.revenue.state.mn.us/businesses/sut/Pages/SalesTaxCalculator.aspx
or call us at the phone number at the bottom of this page.
(Shipments within MN Only) TAXES
We offer a 10% discount on orders of 20 or more books
TOTAL
MAKE CHECK PAYABLE TO JOLA PUBLICATIONS OR COMPLETE CREDIT CARD INFORMATION BELOW.
Credit Card Information: We accept Visa & Mastercard. Sorry, we do not accept Discover or American Express.
Name__________________________________________________________________________________________________
Card Number____________________________________________________________ Security Code ____________________
Expiration Date _________________________Signature _________________________________________________________
Credit Card Billing Address ________________________________________________________________________________
Jola Publications  1828 Jefferson St. NE #201  Minneapolis, MN 55418
Toll Free 866-206-4495  (612) 529-5001  FAX (612) 605-4645  medical@jolapub.com  www.jolapub.com