The American Surgeon

2009 Reprint Order Form

This is your form and/or invoice. All information must be completed or it will be returned. Purchase Orders are not accepted. Please keep a copy of this document for your records. ALL ORDERS AND PREPAYMENTS MUST BE SENT TO ATLANTA. NO PURCHASE ORDERS WILL BE ACCEPTED.

All information below MUST be completed or form will not be processed.

Author Name * Title of Article

Volume Issue Pub. Date # Pages

Ship to:

Insitution (if applicable): Department Tax ID Name of Individual Street Address * Suite * City * State * Zip Code *

Work Phone * Fax * Home Phone * Email * Special Instructions

Paymnent Must be Made in US Dollars

Check or Money Order enclosed. Payment by credit card.

Credit Card Number Security Code Expiration Date
Name as it Appears on the Card

Click “Submit” below!