H.O.T. Guide (Third Edition 2009) Order Form

Your Name:

Company/business name

Address:

Address 2:

City:

State:

Zip-code:

Phone:

Fax:

Email:

Price:

$15.00 per guide with shipping & handling

Quantity:

Sub Total:

Sales Tax 6% (CT Residents):

Total:

Form of payment:

Cash
Check - Make payable to "Northwestern CT AHEC"
Purchase Order#

Tax Exempt Organizations:

State Tax Registration Number

**To receive tax exempt status-please fax state tax exempt form**

For CT based organizations only submit Cert-119. Click here for link to Cert-119

If you have a copy of your tax exempt form on your computer, upload it here:

Tax Exempt Form