ECMO Specialist Training Manual Order Form

Print out the ECMO Specialist Training Manual order form and mail or fax to the address below.

Prepayment is required prior to shipping. 

Please send  ____  copy(ies) of the ECMO Specialist Training Manual to:

Name:     _________________________________________________________________

Address: _________________________________________________________________ 

                _________________________________________________________________

City:         _________________________ State:_______________ Zip:________________

Country:  _________________________

Phone:     _________________________ FAX: _______________________________

E-mail:    _________________________

_____  Manuals @ $35.00 ea. = $ _______           For 1 to 5 manuals

_____  Manuals @ $30.00 ea. = $ _______            For 6 or more manuals

_____  Manuals @ $5.00 ea.   = $ _______            For shipping and handling*

Total:                                            $ _______

* Add  $5 shipping and handling for each manual sent within the 48 contiguous states.  For other countries, Hawaii and Alaska contact the ELSO office for rates.

Circle one: Check enclosed (Payable in U.S. funds to ELSO)        VISA             MasterCard

Card # ______________________________________________ Exp. Date ____/____

Signature: ________________________________________________________________

Mail to ELSO Office, 1327 Jones Dr., Suite 101, Ann Arbor, MI 48105

Phone: (734) 998-6601 or FAX (734) 998-6602