Please print the form provided below for fax or mail orders.

Fax: 301-424-6513
Mail: ROCKPORT INSTITUTE, LTD, 10124 Lakewood Drive, Rockville, MD 20850 USA

• Program Fee: $520 US
• Credit Cards: Visa, Mastercard, Discover, American Express
• Shipping: Free to the United States and Canada. If you want even faster shipping, Federal Express Next Weekday delivery of the testing packet to the U.S. and Canada is $25.
• Worldwide Shipping: Outside the U.S. and Canada, delivery is $20 (via Global Priority or Airmail). For Federal Express of test package: $50 to Mexico; $60 to Europe; $70 to India, Australia and Asia; $90 to Middle East, Africa and South America. (DHL courier service may be more for areas not served by Federal Express.)

SEND THE ROCKPORT CAREER TESTING PROGRAM TO:

Name ________________________________________

Street Address _________________________________

Second Address Line ____________________________

City, State, ZIP________________________________

Home Phone (_____)______________________

Daytime Phone (_____)___________________

Email Address ________________________________

Method of Payment (Sorry, no CODs)

[ ] Check or [ ] Money Order Enclosed.

Charge my: [ ] VISA [ ] Mastercard [ ] American Express [ ] Discover

Credit Card Number ____________________________

Expiration date __________

Signature _____________________________

PRINT EXACT NAME ON CREDIT CARD _____________________________

If the person doing testing is 21 or under, please check this box. [ ]