ONLINE ACCESS ONLY Mail Order or Fax Form - Impulse Survey of Focus Facilities 2010
Complete all 3 sections

Moderator Discount: To qualify you must have rated at least 6 facilities used in 2009 by Jan. 15, 2010.

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 2010 Impulse Survey ONLINE ACCESS ONLY (access good until April 2011)
    DISCOUNT price: US$59.95
    Moderator discount w/ 6-10 ratings (U.S.) US$39.95
    Moderator discount w/ 11-16 ratings: (U.S.) US$29.95
    Moderator discount w/ 17+ ratings: (U.S.) US$19.95
  (3) Payment - choose one: (Note: You will receive a password by email when your order is processed)
  [ ] 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 August 17, 2009