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Mailing List Purchase Request

To request the MDS mailing list, please complete and return the order form and rental agreement with full payment. A sample of the item(s) to be mailed must also be included with this form. All lists are for one-time use only. All requests must be reviewed and approved by the Society's Secretary prior to order completion. The estimated time frame for completion of most requests is 2-3 weeks.

Name:

Company / Institution:

Address:

City:

State / Province:

Zip / Postal Code:

Country:

Telephone:

Fax:

E-mail:

Please provide a full explanation indicating the purpose for use of the MDS mailing list. If more space is required, please attach additional file:

Upload explanation:

Type of List

Pressure sensitive (stick-on) labels

Electronic list (e-mailed in Excel format)

Sorting Criteria

Last Name Alpha

Zip/Postal Code

Country Specific:

Payment Information

Nonprofit Organization - Payment Amount: $200.00 USD

For Profit Organization - Payment Amount: $2,000.00 USD

Payment Type MasterCard VISA American Express Request invoice to submit payment

I understand that the mailing list provided by the International Parkinson and Movement Disorder Society is for one-time rental use only. Under no circumstances may the list be copied, reproduced or duplicated in any form other than for the purpose of the specified mailing.