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1. Print out and complete this order form.
2. Send it to us by one of the following methods:
• Mail your payment in US funds with proof of student status and order form to:
   
  Midwifery Today
  PO Box 2672
  Eugene, OR 97402-0223 USA
   
• Fax your order with Visa or MasterCard number and proof of student status and order form to:
  +1 541-344-1422

Check one:

1 year of Midwifery Today magazine (four issues)—

	$39 US
	$49 Canada/Mexico
	$59 Other International

Contact Information

Please print.

First Name	Last Name

Street Address / P.O. Box	City

State / Province / Region	ZIP / Postal Code	Country

Telephone	Fax	E-mail Address

Payment Information

How will you make your payment?

Check/Money order in US dollars

Visa

MasterCard

Please complete the following items if you are paying by Visa or MasterCard. All prices are in US dollars.

Account number
Expiration date  [ month / year ]
Name of cardholder  [ please print ]
Billing address if different from above  [ please print ]
Billing phone and/or email address  [ please print ]
Signature