Uptodate and ESAP Order Form

Subscription Group Order Form

 Special Group Order: we would like to order one or more licenses to UpToDate, based on the specifications below. PDA software is Windows only and free with an individual subscription.

Name Speciality

Institute

Address City Zip/Postal Code

Country Date (of subscription request)

Multi-User Subscription Options  Multiple Copies: see specification below (…... x) $ ______ Shipping & Handling - Outside North America ( …... X $ 35,00) $ ______

Total $ ______

Specification Name Trainee PDA Renewal Subscriber ID if renewal / Yes / No Yes / No Yes / No Remarks

 Will be paid in advance after invoice  Will be paid in advance by check Please send a pro – forma invoice to us in advance Please send a pro – forma invoice to us in advance

 Will be paid by credit card. Please send a pro – forma invoice afterwards

Credit Card Number: Exp. Date:

Name of the Card Holder:

Signature

UpToDate Inc, 95 Sawyer Road, Waltham, MA 02453 – 3471, USA Phone: +1 781 392 2000 Fax: +1 781 642 8840 www.uptodate.com International Office: tel +31 79 3716143 / fax +31 79 3716177