Quality

Resource

 Systems, Inc. Suite 100  11350 Random Hills Road  Fairfax, Virginia 22030  (703) 352-7393  Fax:(703) 352-9024

ORDER FORM
Ordered by: (Please print or type)	Ship to: (If different than ordered by)
Name                                                             Title	Name                                                                      Title
Organization	Organization
Address	Address
City                                                               State         Zip Code	City                                                                         State               Zip Code
Telephone	Telephone
E-Mail Address

Billing Information:	Credit Card Information:
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Purchase Order Number (Billed orders must be accompanied by a Purchase Order)	Account Number
	Expiration Date
Contact Name	Signature
Telephone	Circle One: VISA / MASTERCARD / AMERICAN EXPRESS

PRODUCT	QTY	MEDIA	COST
2011-2012 Bureau of Health Professions’ Area Resource File		CD-ROM	No Cost
2011-2012 Bureau of Health Professions’ ARF Access System		CD-ROM	No Cost
Shipping and Handling (at $50.00 per CD)		Total Due	$

e-mail: arf@qrs-inc.com                                                                                                                                                                www.arf.hrsa.gov

Purchaser understands that pursuant to 42 U.S.C. § 1320b-10 (relating to publications of the U.S. Department of Health and Human Services), the reproduction or redistribution of the Area Resource File for a fee is prohibited. Further, certain data contained on the file are subject to copyright restrictions and may not be reproduced or redistributed without the prior consent of the copyright owner(s).