Fill in the following form, print it out & and return along with a check, money order or credit card information to:

Human Services Research Institute
7420 SW Bridgeport Rd., Suite #210, Portland, OR 97224
(503) 924-3783 / (503) 924-3789 (fax)

Step 1: Enter Personal Information
Name:		Phone:	(no dashes)
Organization:		Fax:	(no dashes)
Address, Line 1:		E-mail:
Address, Line 2:
City, State, Zip:

Step 2: Select Items to Purchase
Item	Quantity	Price	Subtotal
My Voice, My Choice ~ Curriculum		$120/each	$
My Voice, My Choice ~ Overheads		$60/each	$
Self-Determination and You ~ Manual and CD		$30/each	$
Planning & Giving a Presentation		$30/each	$
Self-Advocates and AmeriCorps*VISTA		$30/each	$
Using Medicaid to Fund Self-Advocacy		$15/each	$
Working Together for Change		$30/each	$
Total (prices include shipping & tax)			$

Step 3: Select Method of Payment
Check or Money Order enclosed (make payment to "HSRI")
Purchase Order / State Voucher (Please fill in the following information)
PO/Voucher #:	(please attach a copy)
Credit Card (Please fill in the following information)
Credit Card #:	(no dashes)   Exp. date:
Credit Card Type:	VISA MasterCard American Express
Step 4: Print Order & Mail/Fax with Payment
Click to print completed order form.