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Please print out this form (type
or print clearly in black ink) and attach sample of your mailing
piece or explanation of planned use. Note: The use of any STFM
list is contingent upon the approval of the mailing piece or planned
use. Please allow 1 to 2 weeks for processing.
Date:
Ship to:
Mail invoice to (if different from ship to):
Purchase Order #:
Demographic breakdown of membership: (Check
one or more; others available on request by calling Mary Ruhl at
800-274-2237, ext. 5404. All counts are subject to change.)
Total Active Membership - $395 (approx. 5000)
Family Medicine Department Chairs - $75 (125)
Family Practice Residency Program Directors
- $100 (470)
Members by State - $25 per state (numbers
vary)
- States desired:
Call for other breakdowns - $100 per 1000 names
(min. chg. $100) plus $50 setup charge
Examples:
Discipline: Full-time faculty family
physicians (3000)
Full-time faculty nonphysicians (850)
Psychologists (150)
Gender: Male (2500) Female
(1700)
Degree: MD, MSW, PhD, etc.
Label Sequence:
Zip
code order
Alpha
order
Other:
US only
US & Foreign
US & Canada
Format:
3-up pressure sensitive(available upon special
request + $50 setup charge)
3.5" disk (Choose one format:
ASCII fixed length
ASCII variable length
Mail merge Word for Windows
Email
Shipping:
First Class Mail
3-day Fed Ex
2-day Fed Ex
1-day Fed Ex (extra charge)
Request Date:
Date Needed:
Agreement: This names and addresses provided
by STFM are the property of STFM are are supplied for the specific
mailing ordered for one-time use only. After completion of
such mailing, any unused labels, list, or disk shall be destroyed
and not used for any other purpose. Lists are seeded with decoy
names to protect against unauthorized use.
Contact:
Phone No.:
Signature: ______________________________________________________
Return this application by mail to:
THE SOCIETY OF TEACHERS OF FAMILY MEDICINE
ATTN: Mary Ruhl
11400 Tomahawk Creek Parkway
Leawood, KS 66211
Or Fax this application to:
Mary Ruhl 913-906-6096
Questions? Contact Mary Ruhl, 800-274-2237, ext 5404
E-mail: mruhl@stfm.org
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