Prostate Cancer Research Institute Pamphlet Order Form

Name: _______________________________________________________

Organization: __________________________________________________

Address: _____________________________________________________

City: _________________________________________________________

State: _______________________ Zip: _____________________

Day Phone: (_____) ________________

Email: _____________________________________________________

Pamphlets cost 10¢ each, and there is a minimum order of 100
Please indicate the number of pamphlets you would like to order:

Number of copies: _____ x 10¢ = $ __________ Total Cost

Make check payable to: Prostate Cancer Research Institute

Or pay by credit card: Visa ___ MC ___ Am Ex ___ Discover ___

Card #: ___________________________________ Exp. Date: ____/____

Name on card: _________________________________________________

Signature: _____________________________________________________


	Working together for a cure	PROSTATE CANCER RESEARCH INSTITUTE 5777 West Century Boulevard, Suite 800, Los Angeles, CA 90045 Phone: 310-743-2116 • Fax: 310-743-2113 • Email: info@pcri.org PCRI is a 501(c)(3) Not-for-profit public charity • US Tax ID: 95-4617875
	"What You Should Know About Prostate Cancer" Pamphlet Order Form Print this page then return by mail or fax to 310-743-2113
	Name: _______________________________________________________ Organization: __________________________________________________ Address: _____________________________________________________ City: _________________________________________________________ State: _______________________ Zip: _____________________ Day Phone: (_____) ________________ Email: _____________________________________________________ Pamphlets cost 10¢ each, and there is a minimum order of 100 Please indicate the number of pamphlets you would like to order: Number of copies: _____ x 10¢ = $ __________ Total Cost Make check payable to: Prostate Cancer Research Institute Or pay by credit card: Visa ___ MC ___ Am Ex ___ Discover ___ Card #: ___________________________________ Exp. Date: ____/____ Name on card: _________________________________________________ Signature: _____________________________________________________