Genetic Testing: Implications for Insurance Order Form

Please fill out the form completely, print and send via mail or fax.

*required information

Name*
Title
Organization
Address*
City
State or Province*
Zip or Postal Code*
Phone*
E-mail*
Product	Genetic Testing: Implications for Insurance
Reduced Price	$20 USD
Quantity
Extended Price
Payment Type*	Check enclosed Visa MasterCard
Card Number
Name on Account
Exp. Date

Signature*	Date

Please make your check payable to The Actuarial Foundation.

Orders must be paid in U.S. dollars. Canadian residents please note that the GST will be charged by Revenue Canada at the source. A $5 Canada Post handling fee may also be applicable.

Mail Order or Fax to:

The Actuarial Foundation
475 N Martingale Rd, Suite 600
Schaumburg, IL 60173-2226

Fax: 847.706.3599

[For office use only: 50-440001-00000-301] W