Chapter List Rental Request Form


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Requestor Information

Requestor Name: *
Requestor Email: *
Requestor Phone : *
999-999-9999
Position in Chapter: *
Chapter Name : *
Please spell out the full chapter name
Chapter Zip Code: *
How will this request be used?: *


If "Chapter educational event" or "Regional meeting" is selected, mail piece is required, upload below
If other, please specify:
Upload mail piece:

Order Requirements

Requested Delivery Date: *
mm/dd/yyyy (allow 10 business days, plus 5-7 days if choosing standard shipping method)
Ouput Format: *

Radius of Zip Code: *
If other, please describe in the Comments section, below.
Maximum number of records you would like:

Shipping Requirements

Delivery Method: *
If "Email" is requested, list address below. If "Ship" is requested, list address in the "Mailing Information" section, below.
Email Address:
Shipping Method:


(Note: If an order requires non-standard shipping method, the chapter will be responsible for the shipping charges and will be billed accordingly.)


Mailing Information

Name:
Street:
City:
State:
Zip Code:
Home Phone:
999-999-9999
Work Phone:
999-999-9999
Fax Phone :
999-999-9999

Comments

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