Jola Publications Medical Directory Order Form Contact Name ______________________________________________________ Purchase Order #________________ Company ________________________________________________________________________________________ Mailing Address __________________________________________________________________________________ Physical Address (if different from mailing address)_______________________________________________________ City _____________________________________ State ________________ ZIP ____________________________ Phone (REQUIRED) (________) ____________________ Dept. __________________________ Email address is only used for shipment notification & receiving this flyer. We do not share with any third parties. Email:_______________________________________________________________________________________ Qty. State Medical Directory Cost Wisconsin (July 2014-2015) $25 Minnesota (September 2013-2014) $25 Minnesota (October 2014-2015) (Pre-Sale for publication date Oct. 2014) $25 Iowa (January 2014-2015) $25 Nebraska (March 2014-2015) $25 North & South Dakota (April 2014) $25 SHIPPING & HANDLING ADD SUBTOTAL Price Total $6 Orders shipped within the state of Minnesota are subject to sales tax. The exact rate varies based on your ZIP code. If you are unsure what tax rate you should be paying, please visit: www.revenue.state.mn.us/businesses/sut/Pages/SalesTaxCalculator.aspx or call us at the phone number at the bottom of this page. (Shipments within MN Only) TAXES We offer a 10% discount on orders of 20 or more books TOTAL MAKE CHECK PAYABLE TO JOLA PUBLICATIONS OR COMPLETE CREDIT CARD INFORMATION BELOW. Credit Card Information: We accept Visa & Mastercard. Sorry, we do not accept Discover or American Express. Name__________________________________________________________________________________________________ Card Number____________________________________________________________ Security Code ____________________ Expiration Date _________________________Signature _________________________________________________________ Credit Card Billing Address ________________________________________________________________________________ Jola Publications  1828 Jefferson St. NE #201  Minneapolis, MN 55418 Toll Free 866-206-4495  (612) 529-5001  FAX (612) 605-4645  [email protected]  www.jolapub.com