Quality Assurance Kit CD-ROM
Information & Order Form

(Print or download form: fax to 301-941-8427 or e-mail to qapdissem@urc-chs.com)

Full Name:   

Title:

Company Name: 

Address : 

City:

State/Province: 

Country:

ZIP/Postal Code:

Email Address:

Daytime Phone:

Fax:  

Please provide a brief description of your duties related to healthcare and to quality assurance.

 

 

 

 

Do you perform any training in healthcare and quality assurance methods? If so, please describe briefly.:

 

The Quality Assurance Projectís prices apply only to orders from North America, Australia, and Western Europe and include shipping and handling. Individuals or organizations in developing countries with headquarters in North America, Australia, and Western Europe must prepay the prices listed on this order form. All funds received are used to provide publications to non-sponsored individuals in Africa, Southeast Asia, the Caribbean, Eastern Europe, and Latin America, for whom products are free of charge.

 

 

 

Product Name

Quantity

Price in $US

Number Ordered

Total

Quality Assurance Kit
CD-ROM

1-5

$20.00 each (includes shipping)

________

$ __________

6-15

$15.00 each (includes shipping)


________

$___________

16 or more

$10.00 each (includes shipping)


________

$___________

Single copies are available free of charge to developing country professionals.

 

Please remit payment by check or money order only:

Make checks and money orders payable to University Research Co., LLC . Mail payment with your order.

Passport # (driver’s license # for U.S. residents): ________________________________________

Signature: _______________________________________Phone #: _______________________

 

Center for Human Services
Communication Division
Quality Assurance Project
7200 Wisconsin Ave, Suite 600
Bethesda, MD 20814-4811

Phone: 301-941-8532
Fax: 301-941-8427

Email: qapdissem@urc-chs.com