HTN Publication Order Form

Name Title 
Organization 
Address 
City 

State

  Zip 
Work # Fax # Home#    

Qty

Item

Cost per Unit

Total 

 HTN State/Local Coalition Directory*

$10.00*

$
 HTN Network (back editions)*   
        Edition:__________ Vol:______ No:______

$7.00*

$
        Edition:__________ Vol:______ No:______

$7.00

$
       - - To order other editions, please specify on an attached sheet.   
 Pregnancy Basics Magazine (sample issue)*

Free

$
 NOAPPP Nutrition Brochure: A Guide for Pregnant and Parenting Teens (1-10 copies at $2.00 each; 11-50: $1.50 ea; 51+: $1.00 ea)

$2.00, $1.50, or $1.00

 $
"Another Chance: Preventing Additional Births to Teen Mothers"

$15.00

$
Shipping & Handling (non-members only)
$ 8.00
Additional Shipping & Handling (please call HTN for quote if ordering multiple copies)
$ 
*One copy is free to Members of HTN (including shipping & handling).            Total Amount Enclosed
$
Payment is enclosed in the amount of $______                   (PO's, checks, credit cards or money orders)
 e  Purchase Order enclosed. I understand that my materials will not be sent until payment is received.
 e Check/Money Order    

 e  Credit Card provided                              VISA  e               MasterCard  e 

Expiration Date ______     Authorization Code __________

 Credit Card # _____________________________________________         
Signature       _____________________________________________

Please mail/fax completed form and payment to:      

HTN- 509 2nd Street, NE, Washington, DC 20002 - fax: 202-547-8815

E-mail: healthyteens@healthyteennetwork.org - Website: www.healthyteennetwork.org - Telephone: 202.547.8814