FMSF Article Order Form Article Mail Order Form Name: Address:

FMSF Article Order Form
Article Mail Order Form


Name: ________________________________________________________________


Address: _____________________________________________________________


______________________________________________________________________
       City                                 State           Zip

Telephone: (_______)________________________


*  MAIL the completed form with payment to: 
FMS Foundation, 3401 Market ST, Suite 130, Philadelphia, PA 19104-3315
Please allow two weeks for delivery

*  FAX your order to (215) 287-1917. Fax orders cannot be processed 
without credit card information.

*  SHIP via FedEx:___overnight___2-day delivery. Please provide FedEx
Account Number and/or Credit Card number in space provided below.

*  FMSF is not able to accept telephone or e-mail orders.

METHOD OF PAYMENT: (Minimum order $25 for credit cards)

___VISA:  Card: #________-________-________-________ exp. date ___/___

___MASTER CARD: #________-________-________-________ exp. date ___/___

___Check or Money Order: Payable to FMS FOUNDATION in U.S. dollars.

___FedEx ACCOUNT #: ______________________________

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Instructions:
   Complete the table below, including both item number and author.
   For overseas airmail add $3 for Europe; $5 for Asia/Africa, Pacific

Quantity  Item no.          Author              Item price  Item total
        |         |                            |          |
________|_________|____________________________|__________|___________
        |         |                            |          |
________|_________|____________________________|__________|___________
        |         |                            |          |
________|_________|____________________________|__________|___________
        |         |                            |          |
________|_________|____________________________|__________|___________
        |         |                            |          |
________|_________|____________________________|__________|___________
        |         |                            |          |
________|_________|____________________________|__________|___________
        |         |                            |          |
________|_________|____________________________|__________|___________
        |         |                            |          |
________|_________|____________________________|__________|___________
        |         |                            |          |
________|_________|____________________________|__________|___________
 ___For_Office_Use_Only___                                |
|                         |        Article sub-total:     |___________
| Check#:________________ |                               |
|                         |         Overseas Postage:     |___________
| Amount:________________ |                               |
|                         |         Total Amount Due:     |___________
|_Date:___________________|