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PURCHASER QUALIFICATIONS AND ORDER FORM
Name:_____________________________________________
Position:___________________________________________
Organization:___________________________________________
Phone Number:(___)_________________________________
Email:_____________________________________________
Address:
___________________________________________________________________ Zip:_______________
Applicant's Education: Highest Degree:_____________________
Field:____________________________________
Date:_____________________
University:___________________________________________________________
Professional Organizations:
_______________________________________________________________________
If applicant is below MA level, give title and name of supervisor or advisor:
Advisor:______________________________________________________________________________________
Address:____________________________________________________________________Zip:_______________
Anticipated use of
Manual:___________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
You will be contacted periodically about your research and experiences with the Manual.
Your cooperation with the authors will be appreciated.
"I agree to supervise personally the use of all confidential material in the
Experiencing Scale Manual and its accompanying tapes."
Applicant's
signature:____________________________________________________Date:___________
Advisor's signature: _____________________________________________________Date:___________
(if applicant is below MA level)
__________ sets of Volumes I and II (@ $26.00) __________
__________ sets of Volume III cds (@ $42.00) __________
total amount enclosed __________
Send Order Form to: Dr. Marjorie H. Klein
Department of Psychiatry
Wisconsin Psychiatric Institute and Clinics
6001 Research Park Boulevard
Madison, Wisconsin 53719-1179
Make check payable to Department of Psychiatry
Ship Manual to:
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