ICAMRL Certificate Plaque
Printable Order Form

*** INSTRUCTIONS ***
While you can complete this form on your computer, certificate plaques cannot be ordered online. After typing your information into the fields below, please print this form and send it to the ICAMRL. If paying by credit card, fax this form to the ICAMRL at 410-872-0030. If paying by check, mail your order to ICAMRL, 8830 Stanford Boulevard, Suite 306, Columbia, MD 21045. All orders must be prepaid; the ICAMRL does not accept purchase orders. Thank you!
NUMBER OF CERTIFICATE PLAQUES REQUESTED: x $40.00 each = $
Price includes shipping and handling. All requests for replacement certificates will be verified to confirm current laboratory accreditation.
SHIP TO: DR. MS. MR.
NAME:
TITLE:
INSTITUTION:
 

ADDRESS:
**No P.O. boxes**

 
CITY: STATE: ZIP:
WORK PHONE: FAX:
EMAIL:
PAYMENT INFORMATION:
TOTAL: $
PAYMENT TYPE: CHECK VISA MASTERCARD DISCOVER
CREDIT CARD NUMBER:
**No spaces or dashes between numbers**
EXP.
DATE:		 **mm/dd/yyyy**
NAME ON CREDIT CARD:
SIGNATURE:
**Please provide signature if paying by credit card**
 
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ICAMRL
The Intersocietal Commission For The Accreditation Of Magnetic Resonance Laboratories
8830 Stanford Boulevard, Suite 306, Columbia, MD 21045
Fax 800-581-7889, Phone 410-872-0100, Toll Free 800-838-2110