Faxable order form

ORDER FORM

Mail or Fax to: MICPEL 520 W. Fayette St., Suite 300, Baltimore, MD 21201-1756
Fax: (410) 659-0647 - E-Mail: info@micpel.edu - (410) 659-6730 (800) 787-0068

Method of Payment

__Check - Check Number___________
(Make checks payable to MICPEL)
__Charge __Visa __Master Card __AMEX

CVV Number___________________________
(VISA & MasterCard last 3 digits on back of card)
(AMEX 4 digits on card front)

Account Number:___________________

Exp. Date____________________

Name on Card:_______________________

Flex/Select Pass Number:___________

Please print or type all information clearly Send or Fax to MICPEL - Credit Card required for fax registrations.

Please include information for

__change of address or
__different shipping address

Name:___________________________

Firm:____________________________

Street Address:________________________

City/State/Zip:_________________________

Phone:_______________________________

Fax:_________________________________

E-Mail:_______________________________

Publications Order Information

Quantity	Inventory Code	Publication Title	Price




		6% Tax
		Shipping (Click here to view shipping rates)
		$10.00 Special Handling Charge (shipped same day)
		TOTAL

Automatic Subscription Update Service
If your publication is periodically updated, you will automatically receive all supplements. Check here if you do not want this service.____

Course Registration Information

Please, only one person per course registration form. Copy this form for additional registrants.

Course #	Course Title	Date	Fee	Location	Credits needed



				Total course fees	$
				PA credits @ $2 per hour	$
Year Admitted_______________ Are you taking course for Credit?________________ State Association________________			Discounts taken for __MSBA Member __Law Student discount __Other discount
*Source: web0400*			Total Payment: $________