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BACK ISSUE ORDER FORM …

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Created: Mon Aug 13 16:03:20 2007
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                     BACK ISSUE ORDER FORM
                                     May/June 2003­Present
                                           (Excluding Nov/Dec 2005)




 Issue                                                                             @$10.00 =
                                    PLEASE PRINT

 Issue                                                                             @$10.00 =

 Issue                                                                             @$10.00 =

 Issue                                                                             @$10.00 =

 Issue                                                                             @$10.00 =

 Issue                                                                             @$10.00 =

                                                                                      Subtotal

                                                          Shipping for foreign orders $5

                                                                                        TOTAL




 Name (PLEASE PRINT)

 Credit Card payment:   American Express     Discover         MasterCard   VISA           Check/Money Order enclosed

 Credit Card#                                                                             Exp. Date       /

 Signature                                                                  Phone#

 Address                                                                    City

 State or Province                                      Zip                 Country


Mail to Psychology Today, 115 East 23rd Street, 9th Floor, New York, NY 10010 or fax to 212-260-7445