Order Form - Impulse Survey of Focus Facilities 2011
Complete all 3 sections

Discount: To qualify you must have rated at least 6 facilities used in 2010 by Jan. 15, 2011
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

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

(2) Pricing
  Cost of the 2011 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.:
    -*Media mail: $6.50 (8 days) + $3 for each additional book to same address
    -Postal Priority Mail: $15.25 + $5 for each additional book to same address

*We cannot track Media Mail. In order to ensure delivery, please provide: suite number,
floor number or internal company code if applicable. Impulse Research is not responsible
for lost or mis-addressed books.

Shipping & handling outside of U.S.
    -Canada and Mexico; Global Priority Mail: US$12 + $5 for each additional book to same address
    -Everywhere Else; Global Priority Mail: US$15 + $8 for each additional book to same address

Number of books ordered: __________ Total payment due: __________

(California residents must add 8.75% sales tax. Subject to increase)
  (3) Payment - choose one:
  [ ] 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 July 7, 2011