Order Form - Impulse Survey of Focus Facilities 2008
Complete all 3 sections

Discount: To qualify you must have rated at least 6 facilities used in 2007 by Feb. 15, 2008.

Complete & sign this form and mail to:
Impulse Research, P.O. Box 506, Culver City, CA 90232-0506
Or fax this page to: 310 839-9770

No FedEx shipping, even with your own account number

 Questions: info@ImpulseSurvey.com or Call: 310 559-6892 USA
All information required
(1)
Name ________________________________________ Title ______________________________
Company ________________________________________________________________________
Address ______________________________________ City _______________________________
State/Province _______________________ Postal-Code ____________ Country _______________
E-mail ________________________________________ Telephone _________________________

(2) Pricing
  Cost of the 2008 Impulse Survey book (includes online access):
    Regular price: US$85; additional copies: US$65
    Moderator discount w/ 6-10 ratings (U.S.) US$65
    Moderator discount w/ 11-16 ratings: (U.S.) US$45
    Moderator discount w/ 17+ ratings: (U.S.) US$25

Shipping & handling for one book in U.S.:
    Postal Media mail: $5 (8 days) + $3 for each additional book to same address
    UPS Ground: $11 + $5 for each additional book to same address
    UPS Next Day air: $55 + $10 for each addional book to same address

Shipping & handling outside of U.S.
    Global International Mail: US$15 per book

No FedEx shipping, even with your own account

 Number of books ordered: __________ Total payment due: __________

(California residents must add 8.25% sales tax)
  (3) Payment - choose one: (Note: credit card orders will not be debited until March 15, 2008)
  [ ] Check - payable to: Impulse Research Corp., P.O. Box 506, Culver City, CA 90232-0506 USA
  [ ] Credit card:         [ ] American Express     [ ] VISA     [ ] MasterCard     [ ] Eurocard
 
     Name __________________________________    Card #: ________________________________

    Expires: ________/________     V-Code__________
 


For fraud protection, please enter your V-Code -- the 4 numbers above the credit card number on the front of your AmEx; or the 3 numbers on the back of your Visa, Eurocard or MasterCard, immediately following your account number.

Page updated January 14, 2008