PsychopharmINFO logo

PsychopharmINFO.com Newsletter
P.O. Box 32825
Baltimore, MD 21282
USA

Please PRINT out this order form, complete it, and mail it with your payment (in U.S. dollars, please) to the above address.

=======================================================

Dear Dr. Daviss:

Please subscribe me to your weekly email newsletter, PsychopharmINFO.

I would like to subscribe for:

___ six months (24 issues) for US$35.00

___ twelve months (48 issues) for US$60.00

Please accept my enclosed payment (check, money order, Visa, MasterCard) made out to PsychopharmINFO.com. Thank you.

NAME: ________________________________

ADDRESS: ___________________________________________   CITY: ______________________________

STATE/PROVINCE: __________________   ZIP:___________   COUNTRY: _________

EMAIL: ______________________________________________ []

PHONE (optional): ________________

=======================================================

For credit cards (Visa or MasterCard only, please):

Name on card: ____________________________________

Billing Address and Zip code: ________________________________________________
(if different from above)

Card Number: _____________________________________

Expiration date (MM/YY): _______________

I agree to pay the above total amount according to card issuer agreement, and authorize you to charge my card for this amount.

X______________________________________

 Authorized signature
L10 Web Stats Reporter 3.1 L10 Hit Counter - Free Web Statistics
LevelTen Web Design - Flash, Website Designers