Publication Form

KENTUCKY HOME HEALTH ASSOCIATION
PUBLICATION ORDER FORM




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Kentucky
Home
Health
Association

 154 Patchen Drive, Suite 90
Lexington, Ky. 40517
Phone:(606) 268-2574      Fax: (606) 269-1124
Billing Address


Name:

Agency:

Address:

City:

State:                        Zip:
          
Phone:
 Shipping/Address


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Agency:

Address:

City:

State:                        Zip:
          
Phone:



6% Kentucky Sales Tax applies to all agencies/organizations not tax exempt (except for copies of regs, and Draft IV Case Management Protocol). If tax exempt and KHHA does not have your tax exempt number on file, please include written verification of status.


KHHA members may be billed for purchases. All others must prepay, and may print a copy of this form and mail with payment.

Publication
Number		 Title Number of
Copies		 Price
Each		 Sub
Total		 Sales
Tax		 S&H Total
Submit this form as needed for additional orders. Grand Total:     
Comments:



Click on to submit your order. Click on to clear your order and start over.

If you wish, you may print a copy of this form and either mail to address above or fax to (606)269-1124.
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