Communication Disorders Software Order Form

Name:
Organization:
Address1:
Address2:
City:
State:	Zip:
Country:	Phone:
Email:

Select the software package(s) you wish to order:

Speech Intelligibility Test – Clinical Package ($250 for one site license)

Speech Intelligibility Test – University Package ($350 for 5 site licenses)

Pacer/Tally Standard ($125)

Payment Method

When ordering, add $4.95 for postage within the U.S. and Canada and $12.95 to countries other than the U.S. and Canada.
Payment Method: Check Visa MasterCard Purchase Order
Credit Card #: Exp. Date:
Name on Credit Card:
Credit Card Approval Signature:
Please complete this form, print it, and then mail it with payment or Purchase Order to:
Madonna Rehabilitation Hospital Attn: Kim Howard 5401 South St Lincoln, NE 68506	Make checks payable to Madonna Rehabilitation Hospital. Payment must be in US dollars. Visa or MasterCard registrations are accepted by mail, phone, fax or via online payment.