MUST HAVE
DOUBLE PLUS MEMBER ID# OR PROMOTION CODE
for
Your special DoublePlus price of $290 (plus $15 S&H) includes six
InfoMaps. Allow two weeks for delivery. If you require RUSH service, a $75 rush
charge will be added to your total.
RUSH ORDER?
YES
($75 Additional) NO
If Rush, Date Needed by:
DOUBLE PLUS MEMBER ID# OR PROMOTION CODE MUST
BE INCLUDED
DOUBLE PLUS ID#:
The Study Area
Radius
Zip Codes
Polygon
(Custom)
Census
Tracts
Please check the box above as it applies to this order
and fill in all information below. Include the name of the Study as you would like
it to appear on your reports and InfoMaps. This section is for the STUDY AREA ONLY—be
sure to fill in all other sections of the Order Form. If you are using a custom
polygon, you must send via mail or overnight express a local road map with the outline
highlighted on the map. The boundary you indicate will be duplicated for your Study
Area. SHIP TO: PERCEPT, 29889 Santa Margarita Pkwy., Rancho Santa Margarita, CA
92688. The local phone number is (949) 635-1282.
For Radius Orders
Your Radius Choice in Miles
Cross Street #1
Cross Street #2
Zip Codes or Census Tracts
(If you have more than seven numbers, include in the Comments box below.)
Click here to first check your ZIP Codes.
Zip Codes
Census Tracts
Comments
Study Area Information
This will appear on your reports
Organization Name
Street address
Address (cont.)
County
City
State
Zip Code
InfoMaps Your first 6 are included
If you do not indicate alternate InfoMaps, we will include
our recommended set of 6, numbers 8, 9, 10, 85, 5 and 13 with your updated report.
Please indicate additional selections in the appropriate section below. They are
just $20 each. If you need to reference the InfoMap Selection List, click the link
below to view. After selecting your InfoMap numbers, use your browser's "Back"
button to return to this form.
Your First Six InfoMaps (replace
these numbers with alternate selection if you wish)
Additional Choices ($20 each)
Customer Information Information required
Your Name
Organization Name
Denomination
Street address
Address (cont.)
City
State
Zip Code
Phone
FAX
E-mail
Shipping Information Information required if different from Customer Information
Name
Organization Name
Street address
Address (cont.)
City
State
Zip Code
Phone
Payment
Please fill in each field in the form below so that your order can be
processed promptly. The special web price for a Ministry Area Profile is $315 plus
$15 for shipping. If you have requested RUSH service, or have requested additional
InfoMaps, these charges will be added to your order total.
Select one of the following
Credit Cards:
VISA
MasterCard
AMEX
NAME AS IT APPEARS
ON CREDIT CARD
CREDIT CARD
BILLING ADDRESS
CITY
STATE
ZIP CODE
CREDIT CARD NUMBER
For your security, we ask for
a Card Identification Number
4 digit American Express ID Number is located on
the front of the card, above the right side of the credit card number; on other
cards the ID Number is located on the back side following the credit card number.
CARD ID NUMBER
EXPIRATION DATE
PRINT THIS FORM FOR YOUR RECORDS PRIOR TO SUBMISSION! If you do not receive an order confirmation by email within 2 working
days,
please call 1-800-442-6277 and let us know.
