Forms

University of Washington

School of Dentistry

Dental Education in Care of Persons with Disabilities

Distance Learning Unit Order Form

Name _______________________ Degree ________ Phone _______________ Fax _________

Mailing Address_________________________________________________________________

Participation in Distance Learning Unit: * $1,500 $ ________

*includes rental of 25 videotaped/dvd lectures, purchase of self-instructional modules, outlines, exams and 70 CE credits. (This price includes Shipping & Handling cost)

Shipping/handling rates: (International rates vary)

WA SALES TAX (9.6%) $ __________

(purchases by WA residents only)

Special Shipping/Handling $ __________

GRAND TOTAL $_________

Please indicate your method of payment:

Check (Enclosed) Credit Card

VISA/MC__________________________ Expires____________ Approval # __________

Cardholder (print name) _________________________________ Signature__________________

Please make checks payable (in US funds) to: UNIVERSITY OF WASHINGTON.

Send payment along with this form to:

Continuing Dental Education, University of Washington , Box 357137 , Seattle WA 98195 .

If you need additional information, please call 206.543.1546, or fax 206.685.8412.

Return videos to this address:

DECOD Program, University of Washington , Box 356370 , Seattle , WA 98195 .

I agree to the following regarding these videotaped/DVD lectures:

Signature: __________________ Due date :____________

1. The videos will be used for educational purposes only.

2. I will not permit the videos to be duplicated.

3. I will return the videos by 1st Class, UPS or express

mail 12 weeks after I receive them.

4. I agree to pay a late fee of $50/week if I keep the videos past the due date.

CDE OFFICE USE ONLY Tapes due ____/____/____

Amt. pd._______________ CK/PO# _____________ BK# _______________ Date ____/____/____

CK Total _____________ Remitter:___________________________________________________

Entered by _____ Date____/____/____ Trans # __________ Tapes/rec sent ____/____/____

By who_____ Tapes returned____/____/____ Transcript sent ____/____/____

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