RAPE TREATMENT CENTER
ORDER FORM
Minimum Order of $5.00. All Orders Must Be Prepaid. Please Allow
4-6 Weeks for Delivery.
Poster Sizes: Small (8.5 x 11") Medium (11 x 14")
Large (17.25 x 21.25")
Poster Costs: Small ($1.00) Medium ($2.00) Large ($3.00)
Please send me the following (indicate quantity):
General Posters
Poster # 01 S _____ (x$1.00) M _____ (x$2.00) L _____ (x$3.00)
Total Cost $__________
Poster # 02 S _____ (x$1.00) M _____ (x$2.00) L _____ (x$3.00)
Total Cost $__________
Poster # 03 S _____ (x$1.00) M _____ (x$2.00) L _____ (x$3.00)
Total Cost $__________
Poster # 04 S _____ (x$1.00) M _____ (x$2.00) L _____ (x$3.00)
Total Cost $__________
"Rape Is A Man's Issue Too" Posters
Poster # 05 S _____ (x$1.00) M _____ (x$2.00) L _____ (x$3.00)
Total Cost $__________
Poster # 06 S _____ (x$1.00) M _____ (x$2.00) L _____ (x$3.00)
Total Cost $__________
Poster # 07 S _____ (x$1.00) M _____ (x$2.00) L _____ (x$3.00)
Total Cost $__________
Poster # 08 S _____ (x$1.00) M _____ (x$2.00) L _____ (x$3.00)
Total Cost $__________
Poster # 09 S _____ (x$1.00) M _____ (x$2.00) L _____ (x$3.00)
Total Cost $__________
Poster # 10 S _____ (x$1.00) M _____ (x$2.00) L _____ (x$3.00)
Total Cost $__________
Encouraging Sexual Assault Victims Posters
Poster # 11 S _____ (x$1.00) M _____ (x$2.00) L _____ (x$3.00)
Total Cost $__________
Poster # 12 S _____ (x$1.00) M _____ (x$2.00) L _____ (x$3.00)
Total Cost $__________
Poster # 13 S _____ (x$1.00) M _____ (x$2.00) L _____ (x$3.00)
Total Cost $__________
Poster # 14 S _____ (x$1.00) M _____ (x$2.00) L _____ (x$3.00)
Total Cost $__________
"Rape Drug" Posters
Poster # 15 S _____ (x$1.00) M _____ (x$2.00) L _____ (x$3.00)
Total Cost $__________
Poster # 16 S _____ (x$1.00) M _____ (x$2.00) L _____ (x$3.00)
Total Cost $__________
Poster # 17 S _____ (x$1.00) M _____ (x$2.00) L _____ (x$3.00)
Total Cost $__________
Written Materials
"Rape Drug" Bookmarks ______ Packages of 100; 50 of each bookmark (x$15.00 per package of 100) Total Cost $ _________
"Drug-Facilitated Sexual Assault" Brochure______ Packages of 50 (x$20.00 per package) Total Cost $ _________
"How It Happens" ______ Magazine/Brochure (x$5.00 per copy) Total Cost $ _________
"Medical Care" Brochure______ Packages of 25 (x$25.00 per package) Total Cost $ _________
"A Resource for College Students" Brochure______ Packages of 25 (x$25.00 per package) Total Cost $ _________
Total of Items Ordered $ _________________
Shipping & Handling (see chart below) $ _________________
TOTAL ENCLOSED $ _________________
Shipping & Handling Charges:
$5.00-$20.00 order add $5.00 S&H
$20.01-$35.00 order add $10.00 S&H
$35.01-$50.00 order add $15.00 S&H
$50.01-$65.00 order add $20.00 S&H
$65.01-$100.00 order add $25.00 S&H
$100.01-$150.00 order add $30.00 S&H
$150.01-$200.00 order add $35.00 S&H
$200.01-$250.00 order add $40.00 S&H
$250.01-$300.00 order add $45.00 S&H
For orders greater than $300, please contact the Rape Treatment Center at (310) 319-4503.
Please ship to:
Name: ________________________________
Position: ________________________________
Organization: ________________________________
Address: _________________________________
City: _________________________________
State: _________ Zip: _____________
Telephone: ( _______) __________________
Enclosed is check # ______________________ made payable to the Rape Treatment Center.
Purchase Order # _______________________ is enclosed.
Please attach check or purchase order to completed order form and mail to address below, OR fax purchase order and this form to (310) 319-4809.
Questions? Please call: Rape Treatment Center 1-800-END-RAPE or (310) 319-4503
Mail to:
Rape Treatment Center
Santa Monica-UCLA Medical Center
1250 Sixteenth Street
Santa Monica, CA 90404