ORDER FORM

GBS/CIDP Foundation International

Product List

Product	Cost	Qty	Total
The Overview for the Lay-Person*	$6.00 per book		$
A Handbook for Care Givers	$3.00 per book		$
CIDP Chronic Inflammatory Demyelinating Polyneuropathy Book	$3.00 per book		$
Teen/Young Adult Handbook	$3.00 per book		$
Caring for a Child with GBS	$3.00 per book		$
GBS Acute Inflammatory Polyneuropathy (brochure)	0.50 each		$
CIDP/Chronic Inflammatory Demyelinating Polyneuropathy (brochure)	0.50 each		$
Miller Fisher Syndrome(brochure)	0.50 each		$
Pillbox	0.50 each
Communication Cards, 43 flip-over pages, Doctor, Nurse, Personal indexes	$20.00 per set		$
Magnets (while supplies last)	$2.00		$
“Climbing to Recovery” DVD	$5.00		$
“CIDP” DVD	$5.00		$
Cookbook Volume II	$5.00		$
GBS/CIDP Piggy Bank (Special Shipping $2.00)	$5.00		$
		Subtotal	$

Shipping & Handling (U.S. ONLY)
Up to $4.00 = FREE
$5.00 - $15.00 = $3.00
$16.00-$25.00 = $4.95
Over $25.00 = Please call the National Office
International orders please contact National Office for pricing
Rush/Overnight Delivery please contact National Office for pricing

Shipping	$
TOTAL	$

To members living outside the U.S. – ALL TRANSACTIONS MUST BE MADE IN U.S CURRENCY. All orders are PRE-PAID. CREDIT CARD PURCHASES MINIMUM OF $15.00 Below $15.00 Please include a check.

First Name Last Name

Billing Address (include business name if mailing to business address)

 Shipping Address if different from billing

City/State/Country Daytime Telephone Number

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VISA/MC/DISCOVER (Card Number) Expiration Date Security Number

Cardholder’s Signature

GBS/CIDP Foundation International

The Holly Building

104 ½ Forrest Ave

Narberth, PA 19072

610-667-0131/(toll free) 1-866-224-3301

e-mail: info@gbs-cidp.org