visABILITIES SECURE ORDER FORM
First Name: Last Name:
Facility: Department:
Address:    
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Deliver To (if different from above)
First Name: Last Name:
Facility: Department:
Address:    
City: State/Province:
Zip/Postal Code: Country:
Contact Information
E-mail:
Fax:
Phone:    
Payment
Master Card Visa PO
PO Number:    
Credit Card Number: Expires:
Name on Credit Card:    
Please enter the anti-fraud code:
This is a three digit code on the back of your card as shown in the picture on the right.
Shipping Method
UPS Ground to US or Canada (shipping charge is included in the purchase price)
Customers are responsible for shipping charges abroad or if 2nd Day or Overnight Delivery are requested
Overnight (Actual Shipping Charges will be Charged)
2nd Day Air (Actual Shipping Charges will be Charged)
Outside Continental U.S. and Canada (Actual Shipping Charges will be Charged)
Order Totals
Qty Description Each Amount
Brain Injury Visual Assessment Battery for Adults $495.00 $
Pre-Reading and Writing Exercises
for Persons with Macular Scotomas 		$25.00 $
Sub-Total: $

Sales Tax:
We are located in Alabama and do not have tax exempt status

 $
Total U.S. : $

Please submit your order only once! There will be a momentary delay for secure processing.

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