Untitled Document

Health Administration Press (HAP) Subscription Order Form
(To complete this form, please fill in information, print, and submit to HAP as directed below)

Please select from the following:	Price:	Foreign Shipping?	Quantity:	Total:
Frontiers of Health Services Management	$125.00	+ $10.00	x
Journal of Healthcare Management	$125.00	+ $10.00	x
		MD residents add 6% sales tax
			Grand Total:

Method of Payment

Bill me (Fax with PO to (312) 424-0014)

Check (Please make payable to Health Administration Press)

Credit Card:

Visa

Mastercard

Discover

American Express

Account Number: Exp. Date:

Cardholder Name:

Signature: ______________________________________________________

Date: ____________________

Shipping Information:
(Please attach separate pages for multiple subscriptions)

Name:

Title/Position:

Institution/Company:

Address:

City/State/Zip:

Country:

Phone Number:

Fax Number:

E-mail Address:

(If paying by credit card please be sure to sign and date before submitting.)

Mail, phone, or fax your order to:
The Foundation of the American College of Healthcare Executives, Subscription Services
1 N. Franklin St., Ste. 1700, Chicago, IL 60606-3529
Phone: (312) 424-9456 Fax: (312) 424-0014

Account Number:		Exp. Date:
Cardholder Name:


Signature:	______________________________________________________

Date:	____________________

Shipping Information: (Please attach separate pages for multiple subscriptions)
Name:
Title/Position:
Institution/Company:
Address:
City/State/Zip:
Country:
Phone Number:
Fax Number:
E-mail Address: