Date
Amount Payable
IMDSA Member - $US25.00
Non-Member - $US30.00
I will be paying by
Personal Cheque
Cashiers
Cheque
Money
Order
Paypal
Last Name
First Name
Address
Phone Number
Email Address (We will deliver your e-book to this address)
Book/s Purchased (US States Only)
Book/s Purchased (US States Only)
Book/s Purchased (US States Only)
Book/s Purchased (US States Only)
If more books required, please add them here
Please indicate the
following
Adult w/mds
Medical Care Provider
Family Member of IMDSA
Organisation
Other (please specify)
Number of books
X Cost
= Total cost $US
E-Books will be sent within one week of recipt of payment. Please mail checks or money orders to
IMDSA
PO Box 1052
Franklin, Texas
77856, USA
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