CSHA MAILING LABEL & ELECTRONIC FILE ORDER FORM

SPEECH PATHOLOGY AND AUDIOLOGY.  THE PROFESSIONS CONCERNED WITH COMMUNICATIVE DISORDERS

Important:

  • 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:
REGION 2:
REGION 3:

 

Statewide:

 

CSHA Districts
(see CSHA District Map):

 

Counties:

 

 

*PLEASE CHOOSE FROM THE FOLLOWING:

CONTACT  INFORMATION:

*Contact Name:

*Phone:

  Fax:

  E-mail Address:

SHIPPING INFORMATION:

*Attention:

*Company Name

*Street Address:

*City:                             

*State:                            

*Zip Code:                     

  Mailing House E-mail Address (if ordering electronic label file)

*PURPOSE OF MAILING/PROMOTION MATERIALS (email as file attachment to katrena@csha.org)

PAYMENT INFORMATION:

BILL to Purchase Order/Requisition/Insertion Order #:

Attention of:

*Company Name:

*Billing Address:

*City:

*State: 

*Zip Code:

 

PAYMENT BY CREDIT CARD

Charge my: MasterCard Visa

Account #:

Exp. Date:

Signature/Authorized User:

 

Once we receive this form and the purpose of mailing document (s), 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 katrena@csha.org.

QUESTIONS/COMMENTS

 

or fill out, print and fax/mail

 

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