Please enclose check or money order (US funds only) payable to the FCLB, or authorize charge to VISA, MasterCard, Discover, or American Express.
All orders shipped via Media Mail unless otherwise requested.
PLEASE rush me the latest FCLB Directory! I have enclosed check, money order, or credit card # to the Federation of Chiropractic Licensing Boards.
| ORGANIZATION: |
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| PERSON ORDERING: |
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| TITLE: |
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PHYSICAL ADDRESS:
(we may use UPS) |
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| MAILING ADDRESS: |
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| CITY, STATE or PROVINCE: |
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| POSTAL CODE: |
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| TELEPHONE NUMBER: |
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| Credit Card Acct. #: |
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| Exp. Date: |
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| 3 or 4-digit Security Code: |
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| Authorization Signature: |
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| email address: |
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| Credit Card orders may be faxed to (970) 356-3599 |
______________# of Directories @ $75 each Total: _________________
Mail your check or money order (in U.S. Funds only) to:
Federation of Chiropractic Licensing Boards
5401 W. 10th Street, Suite 101
Greeley, CO 80634-4400 |
FCLB USE ONLY:
| Order received: |
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| Funds received: |
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| Date mailed: |
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| PHONE MAIL FAX |
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