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Disclaimer

Disclaimer
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International Parkinson and Movement Disorder Society
Main Content

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.