Cognistat, Inc.: Order By Mail

Order By Mail

Cognistat, Inc.
P.O. Box 460, Fairfax, California 94978
www.cognistat.com

- ONLY ORDERS IN COMPLIANCE WITH INSTRUCTIONS WILL BE PROCESSED -

- Purchase Orders may be included with this order form, but NOT substituted for this form and Pre-Payment -

A. Customer Information

Name __________________________________ Organization ______________________________________

Street Address (no P.O. Boxes) _________________________________________________________

City _________________________ State __________ Zip ________ Country ___________________

Phone ______________________ Fax ____________________ Email __________________________

B. Order Details

	Price	Quantity		Total
Cognistat Starter Kit Includes Stimulus Book, Manual, Tokens, 25 Test Booklets	$575.00	x _____	=	_______
Cognistat Manual	$75.00	x _____	=	_______
Stimulus Book	$35.00	x _____	=	_______
Package of 25 Test Booklets	$475.00	x _____	=	_______
Package of 50 Test Booklets	$750.00	x _____	=	_______
Set of 8 Tokens	$35.00	x _____	=	_______
				_______ *Subtotal*
				_______ *Tax* (California residents only: Add 9% sales tax)
				_______ *Shipping* (Customers outside U.S. and Canada: Add $15; International customers are responsible for meeting their own customs requirements.)
				_______ *TOTAL*

Please Choose a Language: _____ English _____ Spanish (Test materials will be printed in this language)

C. Reminders

• If you are located outside the U.S. or Canada, did you remember to include shipping costs above?
• If you are a California resident, did you remember to include your sales tax above?

D. Payment Information

•  Make check or money order payable to Cognistat, Inc.
•  Mail completed order form with payment to: Cognistat, Inc., P.O. Box 460, Fairfax, CA 94978.
•  Purchase Orders may be included, but not as a substitute for a completed order form and pre-payment.

If you prefer to place your order using a credit card, please call 800-922-5840 or visit www.cognistat.com.