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	$5.00 per book
Caring for a Child with GBS	$3.00 per book
GBS Acute Idiopathic Polyneuritis (brochure)	0.50 each
CIDP/Chronic Inflammatory Demyelinating Polyneuropathy (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 or VHS	$10.00		$
“CIDP” DVD	$10.00		$
Stationary (while supplies last)	$5.00		$
T-Shirts – Sizes ( L * XL) (while supplies last)	$5.00		$
Cookbook Volume II	$7.00		$
GBS/CIDP Piggy Bank (Special Shipping $2.00)	$5.00		$
		Subtotal	$

Shipping & Handling (U.S. ONLY)
Up to $5.00 = FREE
$6.00 - $15.00 = $3.00
Over $16.00 = $4.95
International orders please contact National Office for pricing
Rush/Overnight Delivery please contact National Office for pricing

TOTAL $_________

To members living outside the U.S. – ALL TRANSACTIONS MUST BE MADE IN U.S CURRENCY. All orders are PRE-PAID.

First Name Last Name

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

City/State/Country Daytime Telephone Number

- - - / /

VISA/MC/DISCOVER (Card Number) Expiration Date

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