Prehospital and Disaster Medicine
Subscription Form

Please print out this form, fill it out, and fax or mail to:
Prehospital and Disaster Medicine
3330 University Avenue, Suite 300
P.O. Box 55158
Madison, WI 53792
USA
Fax: (+1) 608-265-3037

Check "Individual" or "Institutional"

 

1 Year (6 Issues)

__Individual

$120

__Institutional

$400

Please Check one of the following: ___New subscriber __Renewing subscriber

 

__ Payment Enclosed
__ Bill Me
__ Visa
__ MasterCard

Card #______________________________________ Exp. Date___________

Signature________________________________________________________

Name___________________________________________________________

Title_____________________________________________________________

Address__________________________________________________________

City_______________________________ State___________ Zip____________

Country___________________________ Telephone Number________________

Fax Number___________________ E-mail Address_________________________

 

Please do NOT attempt to e-mail this form.

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