Interchange Order Form -- Printed Copies

Please submit this form to order Interchange newsletters. You can decide to receive a proof by e-mail or fax. Payment is due when you approve the proof. If you have any questions, please contact hklein@psyfin.com or call 800-869-8450.

Please provide the following contact information:

First Name

Last Name

Organization

Street Address

Address (cont.)

City

State/Province

Zip/Postal Code

Country

Work Phone

FAX

E-mail

Web site

What issue and number of newsletters do you want?

Number of copies?

Which issue?

Choose one of the following options:

Option A Color: White
                Color: Ivory
Option B Fold to business envelope (#10)
                No fold
Option C Add my picture to Page 2
                No picture

What information do you want at the top of Page 1?

Name          Organization  Address       Phone       
Fax           E-mail        Web site

What information to you want at the bottom of Page 2?

Name          Organization  Address       Phone       
Fax           E-mail        Web site

Questions or suggested modifications. If you want your InterChange order shipped to a different address, enter that here:

11/16/2010 02:34:46 PM

First Name
Last Name
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
FAX
E-mail
Web site

Interchange Order Form -- Printed Copies

Revised: November 16, 2010