ICANL 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 ICANL. If paying by credit card, fax this form to the ICANL at 800-581-7889. If paying by check, mail your order to ICANL, 8830 Stanford Boulevard, Suite 306, Columbia, MD 21045. All orders must be prepaid; the ICANL 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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ICANL
The Intersocietal Commission For The Accreditation Of Nuclear Medicine Laboratories
8830 Stanford Boulevard, Suite 306, Columbia, MD 21045
Fax 800-581-7889, Phone 800-838-2110