First Name		Last Name
Title
Organization
Address
City			State
zip
E-mail

Please provide the following ordering information:

QTY	DESCRIPTION:/Product ID/Name	Price	Total
	Item Total	Price Total
	Pennsylvania Sales Tax 6%	Sales Tax
		Shipping
		Total

Make Checks and Money Orders payable to: Therapy Resources INC.

Shipping 

If your order total is: up to $9.99 add $5.00

• $10.00 - $39.99     add   $6.00

• $40.00 - 99.99       add   $7.50

• $100.00 - $199.00  add   $10.00

• $200 and up          add   $11.00

	BILLING
Purchase Order #
Account Name
Contact Person
Contact Phone

To fax a purchase order: 215-619-0118

	SHIPPING (if Different)
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country

Non Profits Enter your TIN... in the space provided below.