Good Practice Examples Database Subscription Form

Sign up online at http://www/jcrinc.com/gpdatabase if paying by credit card. Or send your check along with this completed registration form to: Joint Commission Resources, P.O. Box 75751, Chicago, IL 60675-5751, Attn: Good Practice Database Subscription

Registration Information:

Name (Please include any professional credentials):

______________________________________________________________________

Title: _________________________________________________________________

Organization: __________________________________________________________

Address: ______________________________________________________________

City/State/Zip: __________________________________________________

Telephone Number (including area code): ________________________________

Fax Number (including area code): ________________________________

E-mail Address: ________________________________

Indicate Method of Payment:

Note: Payment in U.S. funds must accompany completed registration form. Registration forms received without payment will not be processed until payment has been received. Prices subject to change without notice.

_____ Check, payable to Joint Commission Resources (check must accompany registration form)
_____ VISA
_____ MasterCard
_____ American Express

Annual Subscription Cost per User: $199

Annual Site License Subscription: $899

Credit Card Number: ______________________________________

Cardholder's Signature: ______________________________________

Cardholder's Name: __________________________________________

Expiration:____________________________

Telephone Number (including area code): ____________________________

Upon receipt of order form and payment, a login and password will be furnished via e-mail.