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8401 Connecticut Avenue, Suite 900<br />

Chevy Chase, MD 20815-5817<br />

Phone (301) 941-0210; Fax (301) 941-0257<br />

societyservices@endo-society.org<br />

FEIN 73-0521256<br />

THE ENDOCRINE SOCIETY<br />

GUIDELINE ORDER FORM<br />

(Single reprint request for orders of 100 and less)<br />

PRODUCTS QUANTITY PRICE SUBTOTAL<br />

Member Non-Member<br />

Testosterone Therapy in Adult Men with Androgen Deficiency<br />

Syndromes: An Endocrine Society <strong>Clinical</strong> Practice Guideline $15.00 $20.00<br />

Miscellaneous<br />

TOTAL All prices include sales tax $<br />

PAYMENT INFORMATION: ❍ Check ❍ MasterCard ❍ Visa<br />

Card Number<br />

Expiration Date<br />

Billing Address<br />

Signature<br />

Are you a member of The Endocrine Society? ❍ Yes ❍ No<br />

If you are a member and you know your member ID, please provide: ___________________________________________________________<br />

Prefix: First Name (Given): Middle: Last (Surname):<br />

Institution/Company:<br />

Dept/Div:<br />

Street/PO:<br />

City: State/Province: Zip/Mail Code: Country:<br />

Telephone: Fax: Email:<br />

Degree(s) that you would like listed after your name: Professional Title: Date of Birth: Gender:<br />

❍ Male<br />

❍ Female<br />

Which of the following best describes your primary professional role?<br />

Race or Ethnic Affiliation (voluntary)<br />

(Please mark only one)<br />

❍ African American, Black<br />

❍ Administrator ❍ Retired ❍ Asian<br />

❍ Basic Researcher ❍ Teacher/Educator ❍ Hispanic<br />

❍ <strong>Clinical</strong> Practitioner ❍ Fellow (<strong>Clinical</strong>) ❍ Native American, Eskimo, Aleut<br />

❍ <strong>Clinical</strong> Researcher ❍ Fellow (Postdoctoral/Research) ❍ Pacific Islander<br />

❍ Industry/Corporate Professional ❍ Student ❍ White, Caucasian<br />

❍ Nurse/Healthcare Professional ❍ Other___________________________________ ❍ Other___________________________________

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