MARYLAND
REQUEST FORM
Thank you for requesting
the Maryland Pharmacy Laws Book which includes a searchable CD. To place
your order, please print this form, complete it and mail along with a $35.00 check or money order payment. Please do not send cash.
Please make checks/money
orders payable to:
Please mail your request
form to:
Your
Name:
___________________________________________________
Your
Organization: _______________________________________________
Mailing
Address: _________________________________________________
City:
________________________
State: ________ Zip: _________
Telephone
# (
) ________ Ext.______ Fax
# ( ) ______________
Email Address:
___________________________________________________
Type
of Business:
Distributor _____________________
Pharmacy
Chain _____________________
Independent _____________________
Legal/Regulatory _____________________
Other _____________________
Number of Copies: _______ @ $35.00 per copy / Payment enclosed:
$___________
Your copy(s) will be
mailed to you in 7-10 business days. Thank you.
Revised
July 2009 pg