2010 Inventory for Client and Agency Planning™ (ICAP™) Order

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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.