DATE: Name: Shipping Address: Email Address:
KNIT/POLO SHIRTS (Yellow with AMSSM logo): $30.00 each Small Quantity Medium Quantity Large Quantity X-Large Quantity 2X-Large Quantity HATS (Khaki): $15.00 each Hat w/green AMSSM logo - Quantity Hat w/navy blue AMSSM logo - Quantity BROCHURES (100/LOT): $75.00/lot What is a Sports Medicine Physician? - Quantity What is a Sports Medicine Specialist? - Quantity The Sports Medicine Specialist - Could it be a career for you? Quantity
PRESSURE SENSITIVE ADDRESS LABELS: There is a $200.00 charge for AMSSM Members for the entire set of Membership Labels. Non-Members will be charged $250.00 for the entire set of AMSSM Membership labels. Enter the intended use for these labels in the section below. In addition, you will need to send us a copy of the information you would be distributing to our members. This can be sent through email to office@amssm.org or you can fax it to (913) 327-1491. Your request will be processed upon approval of the label use.
Address: Address: City : State or Province : (For USA & Canada use, Please use standard 2 letter abbreviation) Zip or Postal Code: Telephones: (please use xxx-xxx-xxxx form) Phone: Fax: BILLING INFORMATION Name on Account: MasterCard Visa Discover Account #: Expiration Date:
Input Field that are followed by are required - thanks