4919 Route 22, PO Box 56 • Amenia, NY 12501-0056 • Phone: (800) 221-1592 • Fax: (518) 789-0556 • www.salempress.com • csr@salempress.com SALEM PRESS Authorization: Date___________________ PO#______________________________ Sales Representative_________________________________ Bill to_____________________________________________________ Ship to______________________________________________ Institution________________________________________________ Institution___________________________________________ Address___________________________________________________ Address_____________________________________________ City________________________ State ____ Zip_________________ City________________________ State ____ Zip___________ Tel: (____) _________________Fax: (____)______________________ Attention____________________________________________ E-mail_________________________________________________________________________________________________________ q Do not invoice until purchase order is received. Approximate date:_____________________________________________ ORDER FORM Special Instructions: HOLD FOR P.O. NUMBER: q YES q NO • DOES YOUR LIBRARY WANT PROCESSING: q YES q NO ALLOW 4-6 WEEKS FOR ATTACHED PROCESSING. q CHECK HERE TO AUTHORIZE INSTANT ACTIVATION OF YOUR TITLES ONLINE! WE WILL ACTIVATE YOUR TITLES UPON RECEIPT OF YOUR ORDER SO YOU CAN START USING THEM RIGHT AWAY! Published & Distributed by Grey House Publishing Order Total: Subtotal: Shipping: (add 4%) Discount schedule for Libraries & Institutions 3-9 Titles 10-35 Titles 36+ Titles Discounts are per order and do not apply to prepub prices 5% 10% 15% Qty Item No. Description Library Price Discount Price Total 128