EASY HCFA 485 Form Filler©

        Ordering  Form

Please complete this form, print it and enclose it with your payment
(check or money order please).

[FrontPage Save Results Component]

Please provide the following contact information:

Your Name
Title
Organization
Street Address
Address (cont.)
City
State
Zip Code
Work Phone
E-mail

Please provide the following product information:

Product Name  @ $55.00*  Quantity   

                                                total

*available as a very easy download from our web site
Add $7.50 S&H if you prefer the program on disk
Product Name   Quantity 
Version of
Microsoft Word
Operating System

SHIPPING  (if same as above enter same)
Street Address
Address (cont.)
City
State
Zip Code
   

Make checks  payable to
K.L. Laytin, Ph.D.

send  to 
K.L. Laytin, Ph.D.
EASY HCFA Software©  
56 So. Meadow Road 
Plymouth, MA  02360
  Print this Form and mail it along with your payment
K.L. Laytin, Ph.D.
Copyright © 2003-2004  K.L. Laytin, PhD.  All rights reserved.
Revised: 03/24/04