2010 Inventory for Client and Agency Planning™ (ICAP™) Order
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Page 1 of 1 2010 Inventory for Client and Agency Planning™ (ICAP™) Order Form Date ____ /____ /____ Payment Information Please print or type and complete all blanks. In “Charge To” section, indicate address Purchase Order Number where your credit card statement is sent to (if different from “Ship To” address). Charge my credit card: Payment enclosed $ Visa MasterCard American Express Diners Club Discover Exempt from state sales tax. (Please attach copy of certificate) Cert. no. Card Number Cert. Expiration Date Expiration Date Choose One: Test Purchaser Qualification Form attached Authorized Signature Test Purchaser Qualification Form on file at Riverside Note: Orders from first time purchasers require a Test Purchaser Qualification Form and must be accompanied by a check or credit card number. Charge to: (See note above) Ship to: (if different from billing address) Name Name Position Position Organization Organization Billing Address Billing Address City State Zip City State Zip Phone: ( ) Fax: ( ) Phone: ( ) Fax: ( ) E-mail address E-mail address Item and Packaging Code Number Quantity Catalog Price Total Price ICAP Complete Program Y21-922892 _____________ $196.00 _____________ Includes Examiner’s Manual and 25 Response Booklets Pkg. 25 Response Booklets Y21-922891 _____________ $76.00 _____________ Spanish ICAP Complete Kit Y21-922157 _____________ $196.00 _____________ Includes English Examiner’s Manual and 25 Spanish Response Booklets Pkg. 25 Spanish Response Booklets Y21-922156 _____________ $76.00 _____________ Compuscore for the ICAP ® Y21-922884 _____________ $334.00 _____________ Microsoft® Windows® Version 2.1 CD-ROM Order Subtotal _____________ State Sales Tax _____________ Shipping Service Fee* _____________ Order Total _____________ * A shipping service fee is prepaid and added to the invoice. Estimate 10% ($10.00 minimum) for ground shipping; 15% ($10.00 minimum) for Second Day Air and shipping to AK and HI; 17% ($20.00 minimum) for Next Day Air shipping; and 25% for international shipments. Ground transportation available for AK and HI upon request. 3800 Golf Road, Suite 100, Rolling Meadows, IL 60008 phone 800-323-9540 fax 630-467-7192 www.riversidepublishing.com Prices are valid until December 31, 2010 and are subject to change without notice.