Label Request Form - Sgo Page 2

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Label Request Form
: _____________________________
______________________________
Today's date
Date needed:
Please allow at least one week for processing and approval
_____________________________
____________________________________
Requester:
Ship to:
_____________________________
__________________________________________
_____________________________
__________________________________________
_____________________________
__________________________________________
Phone:
Email Address: ____________________________
Please send the labels to:
Requester address
Ship to address
If payment by check: Make check to: Society of Gynecologic Oncology
Mail to: Society of Gynecologic Oncology
26533 Network Place
Chicago, IL 60673-1265
Payment must be received before the labels will be processed.
Credit Card Type:
Visa
American Express
MasterCard
Credit Card Number_________________________________________________________________________
Expiration Date_______________________________V code________________________________________
Name on Card__ ____________________________________________________________________________
Total Charge_______________________________________________________________________________
Would you like your labels shipped via FedEx for an additional charge of $20.00?
YES
NO
What is the purpose of your mailing? _________________________________________________________
PLEASE ATTACH A COPY OF THE MAILING PIECE.
Please check complete or partial list and all that apply:
Complete list (approx. 1800 names)
International Only
USA Only
Gynecologic Oncologists Only
MEMBER TYPES
Full
Associate
Candidate
Fellow-in-Training
Senior
Allied
International
Resident
SIGNATURE REQUIRED FOR COMPLETION OF LIST ORDER
one-time use only
I understand and agree that this list order is for a
to be used only to send material here with
submitted for review by SGO on the date to be sent specified above. A separate order form must be submitted and
approved before using the SGO names again.
Signature__________________________________________________________________ Date: _______________

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