University of Washington
School of Dentistry
Dental Education in Care of Persons with Disabilities
Distance Learning Unit Order Form
Name _______________________ Degree ________ Phone _______________ Fax _________
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 ____/____/____