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NeuroTek Products Order Form      (Please print legibly)
 Qty  Item Description  Unit Cost  Shipping     Total    
    $ $ $
         
         
         
         
The manufacturer will adjust shipping & handling charges if necessary
TOTAL $

MasterCard____   VISA ____   AmEx _____

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Credit Card Account Number
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Exp. Date

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Name, exactly as it appears on credit card
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E-mail Address
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Ship to:
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Name
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Street Address (can not ship to P.O. Box)
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Street Address (continued)
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City,  State,  Zip (Postal)code,  Country
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Phone Number, including area code (required)
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Credit Card Billing Address (if different than above)
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Street Address and Zip/Postal Code

Signature

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IMPORTANT NeuroTek instruments can only be purchased by clinicians trained in EMDRIA- approved programs. Please provide the information below.
  lightbar spacerEMDRIA approved training?__ (Y/N)
  lightbar spacer Date of training ___________
  lightbar spacer EMDRIA member? ____(Y/N)
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  EMDRIA approved trainer's name

3 easy ways to order:


1.   Fax this order form to
      519-883-8907.
2.   Phone the info on this form to
      519-884-8621
3.   Mail this form and your credit
card information to:

EMDRresources.com
651 Columbia Forest Blvd.
Waterloo, ON, Canada N2V 2K7