CSHA Mailing Label & Electronic File Order Form

Fields marked with * are required

To select multiple options, press the control button on your keyboard while making your selection

MEMBER STATUS*
 PROFESSION*
 
EMPLOYMENT SETTING*
 LANGUAGE SPECIALTY*
 
RECORD ORDER*
  

REGION: PLEASE CHOOSE FROM ONLY ONE REGION CATEGORY BELOW (Either Statewide, CSHA District or Counties)

REGION 1
Statewide
  
 
REGION 2
CSHA Districts
 REGION 3
Counties

(see CSHA District Map):
PLEASE CHOOSE FROM THE FOLLOWING:*
CONTACT INFORMATION:
Contact Person:*
Business Phone:*
Fax:
Email Address*
SHIPPING INFORMATION:
Attention:*
Company Name:*
Address:*
City:*
State:*
Zip:*
Email:*
(if ordering electronic label file)
PURPOSE OF MAILING/PROMOTION MATERIALS*
PAYMENT INFORMATION:
BILL to Purchase Order/Requisition/Insertion Order #:
Attention of:
Company Name:*
Billing Address:*
City:*
State:*
Zip:*
PAYMENT BY CREDIT CARD:
Credit Card #:      Exp. Date:
Auth. User:
Comments:

Once we receive this form, CSHA will generate a report based upon the criteria chosen and fax back a Label Authorization form to let the requestor know of the record count and cost. Upon the receipt of the Label Authorization form, CSHA will process and mail/send your order. Submit questions/comments to Ben@csha.org.



CALIFORNIA SPEECH-LANGUAGE-HEARING ASSOCIATION

Attention: Mailing Label/Contact List Order
825 University Avenue
Sacramento, California 95825
PHONE: (916) 921-1568 or FAX (916) 921-0127

 
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