Certificate Order Form

Transcription

1 AMERICAN BOARD OF FACIAL PLASTIC AND RECONSTRUCTIVE SURGERY, INC. Certificate Order Form IMPORTANT ORDER INFORMATION: Certificate orders will be processed only twice a year to take advantage of special group purchasing discounts. Accordingly, group orders will be placed each summer and fall, approximately eight weeks following the biannual meetings of the ABFPRS Board of Directors. Orders can be processed individually, but a $75 surcharge will be added to special orders. No order will be processed until this form has been completed and returned with full payment. Please allow weeks from the order deadline posted in the upper righthand corner for processing. All prices include shipping and handling. 1. YOUR NAME. Print or type your name exactly as you want it to appear on your ABFPRS certificate. Indicate "M.D." or "D.O.," as appropriate. Certification Date: (MM, DD, YYYY) Expiration Date: (MM, DD, YYYY) 2. CERTIFICATES. Indicate the number of certificates you want for the various rooms in your office(s). Certificates are priced separately from framing options below. One unframed ABFPRS Certificate Complimentary* Each additional ABFPRS Certificate $ * All ABFPRS Diplomates are entitled to only ONE complimentary certificate at time of certification. ABFPRS reserves the right to alter the certificate design from time to time without issuing new certificates to Diplomates who placed earlier orders. CERTIFICATE(S) SUBTOTAL 3. FRAMING. If you wish to have your certificate(s) framed, mark the appropriate category below. Prices are in addition to certificate prices quoted above. Please allow an additional 2 weeks for framing orders. Fl Standard Deluxe Frame Hardwood Ebony Finish $82.40 F2 Walnut Frame Solid American Walnut $97.85 F3B Recessed Plaque Blonde Oak $ F3R Recessed Plaque Rosewood $ F3W Recessed Plaque Walnut $ F4 Classic Frame Silver Anodized Finish $ F5 Classic Frame Gold Anodized Frame $ F6 Rustic Oak Frame Rustic Finish, Solid Oak $ F7 Baronial Frame Fine Grain Dark Walnut Finish $515.00

2 F8 Dutch Master Antiqued Dark, 22K Gold Trim $ FRAMING SUBTOTAL

3 4. DURA PLAQUING. If you want your certificate(s) permanently sealed under rigid vinyl and laminated onto a panel, mark the appropriate box below. Prices are in addition to certificate prices quoted above. DB Black Gloss Border Golden Trim $ DW Walnut Gloss Border Golden Trim $ DWL Walnut Linen Border Golden Trim $ DURA PLAQUING SUBTOTAL 5. PHOTOENGRAVING. If you wish to have any certificates produced as photoengraved images, mark the appropriate category below. Please allow 6-8 weeks additional for photoengraving orders. No purchase of certificates required for photoengraving. PEB-9 Solid Brass Finish Approximate Size: Walnut 9 x 11; metal 6 1 / 2 x 8 3 / 4 PES-9 Satin Silver Finish Approximate Size: Walnut 9 x 11; metal 6 1 / 2 x 8 3 / 4 PEB-11 Solid Brass Finish Approximate Size: Walnut 11 x 14 1 / 2 ; metal 8 1 / 2 x 11 PES-11 Satin Silver Finish Approximate Size: Walnut 11 x 14 1 / 2 ; metal 8 1 / 2 x 11 PEB-14 Solid Brass Finish Approximate Size: Walnut 14 x 18; metal 11 x 15 PES-14 Satin Silver Finish Approximate Size: Walnut 14 x 18; metal 11 x 15 $ $ $ $ $ $ PHOTOENGRAVING SUBTOTAL SHIP ORDER TO: Name: Street Address: Building or Suite No.: City, State (or Province), Zip Code:

4 Telephone:

5 PAYMENT INFORMATION All orders must be paid in U.S. dollars by check or credit card. A 3% discount is offered for orders paid by check. Please mail payment to: American Board of Facial Plastic and Reconstructive Surgery 115C South St. Asaph Street Alexandria, VA Enclosed is my check payable to ABFPRS Please charge to my: Visa Mastercard American Express Discover Account # Expiration date CID# (3 or 4 digits located on back of card after account #) Print name on card Signature QUESTIONS? Call (703) ORDER SUMMARY: Certificates Subtotal $ Framing Subtotal $ Dura Plaquing Subtotal $ Photoengraving Subtotal $ Order Subtotal $ Discount (deduct 3% if paying by check) minus $ TOTAL ORDER $

6 NEW You can now order on-line. Visit and click on diplomate resources. Please note that the same deadlines and restrictions do apply.