BCGN Handbook/CD-ROM Order Form

Breast Cancer Genetics Network of Michigan UNDERSTANDING CANCER & GENETICS A Counseling Handbook & Interactive CD-ROM Order Form Name: ________________________________________________________________________ Institution: _________________________________________________________________ Address: _____________________________________________________________________ City: ____________________________ State: ____________________ ZIP: __________ Telephone: _______________________ Fax: ______________________ e-mail: __________________________ (For Office Use Only: Invoice No. _________) Item Description Price Each Quantity Charges Understanding Cancer and Genetics Book (English) $75.00 x __________ $____________ Understanding Cancer and Genetics Book (Spanish) $75.00 x __________ $____________ Understanding Cancer and Genetics CD-ROM (English) $50.00 x __________ $____________ Understanding Cancer and Genetics Book and CD-ROM Package (English) $100.00 x __________ $____________ TOTAL: $____________ Please make all checks payable to The Regents of the University of Michigan Mail your order form with payment to: Sofia D. Merajver, MD, PhD 1500 E. Medical Center Drive 7217 CCGC, 0948 Ann Arbor MI 48109-0948 Breast Cancer Genetics Network of Michigan Telephone: (734) 764-2248 Fax: (734) 647-1564