2010 Logramos® Form A Order Form - Riverside Publishing

2010 Logramos ® Form A Order FormDate_____ /____ /____Payment InformationPlease print or type and complete all blanks. In “Charge To” section, indicate addresswhere your credit card statement is sent to (if different from “Ship To” address).Charge my credit card:Visa MasterCard American Express Diners Club DiscoverCard NumberExpiration DateAuthorized SignatureCharge to: (See note above)NamePositionOrganizationBilling AddressCity State ZipPhone: ( ) Fax: ( )E-mail addressPurchase Order NumberPayment enclosed $Exempt from state sales tax. (Please attach copy of certificate)Cert. no.Cert. Expiration DateChoose One: Test Purchaser Qualification Form attachedTest Purchaser Qualification Form on file at RiversidePage 1 of 3Note: Orders from first time purchasers require a Test Purchaser QualificationForm and must be accompanied by a check or credit card number.Ship to: (if different from billing address)NamePositionOrganizationBilling AddressCity State ZipPhone: ( ) Fax: ( )E-mail addressItem and Packaging Code Number Quantity Catalog Price Total PricePretest MaterialsPractice TestsFor Machine-Scorable BookletsPkg. 25, includes Directions for AdministrationLevel 5/6 Y21-949109 ______________ $27.60 _____________Level 7 and 8 Y21-949112 ______________ $27.60 _____________Level 9 Y21-949115 ______________ $27.60 _____________Subtotal for this page_____________Continued, next page3800 Golf Road, Suite 100, Rolling Meadows, IL 60008phone 800-323-9540fax 630-467-7192www.riversidepublishing.comPrices are valid until December 31, 2010 and are subject to change without notice.

2010 Logramos Form A Order Form, ContinuedPage 2 of 3Item and Packaging Code Number Quantity Catalog Price Total PricePractice Tests (Continued)For Reusable Test BookletsPkg. 25, includes Directions for AdministrationLevel 10-12 Y21-949118 ______________ $27.60 _____________Level 13-15 Y21-949121 ______________ $27.60 _____________Level 16-18 Y21-949124 ______________ $27.60 _____________Practice Tests, Directions for AdministrationFor Machine-Scorable BookletsSingle copyLevel 5/6 Y21-949108 ______________ $5.72 _____________Level 7 and 8 Y21-949111 ______________ $5.72 _____________Level 9 Y21-949114 ______________ $5.72 _____________For Reusable Test BookletsSingle copyLevel 10-12 Y21-949117 ______________ $5.72 _____________Level 13-15 Y21-949120 ______________ $5.72 _____________Level 16-18 Y21-949123 ______________ $5.72 _____________A Message to ParentsDesigned to be used before testing, this pamphlet providesparents and students with information about the Logramosquestion and answer formats as well as the way test results will beused by the school. Available in Spanish only.Pkg. 25Level 5-8 Y21-949127 ______________ $34.81 _____________Level 915 Y21-949129 ______________ $34.81 _____________Level 16-18 Y21-949131 ______________ $34.81 _____________Test MaterialsMachine-Scorable Test BookletsPkg. 25, includes Directions for AdministrationLevel 5/6 Y21-1447625 ______________ $166.87 _____________Level 7 Y21-1447627 ______________ $166.87 _____________Level 8 Y21-1447629 ______________ $166.87 _____________Level 9 Y21-1447631 ______________ $182.97 _____________Reusable Test BookletsPkg. 25, includes Directions for AdministrationLevel 10 Y21-1447633 ______________ $150.64 _____________Level 11 Y21-1447637 ______________ $150.64 _____________Level 12 Y21-1447641 ______________ $150.64 _____________Level 13 Y21-1447645 ______________ $150.64 _____________Level 14/15 Y21-1447649 ______________ $150.64 _____________Level 16-18 Y21-1447653 ______________ $150.64 _____________Subtotal for this page_____________Continued, next page3800 Golf Road, Suite 100, Rolling Meadows, IL 60008phone 800-323-9540fax 630-467-7192www.riversidepublishing.comPrices are valid until December 31, 2010 and are subject to change without notice.

2010 Logramos Form A Order Form, ContinuedPage 3 of 3Item and Packaging Code Number Quantity Catalog Price Total PriceDirections for AdministrationAdditional copies of Directions for Administration may be orderedseperately.Single copyLevel 5/6 Y21-949061 ______________ $20.41 _____________Level 7 Y21-949065 ______________ $20.41 _____________Level 8 Y21-949069 ______________ $20.41 _____________Level 9 Y21-949073 ______________ $20.41 _____________Level 10-14/15 Y21-949077 ______________ $20.41 _____________Level 16-18 Y21-949093 ______________ $20.41 _____________Answer DocumentPkg. 25, includes material needed for machine scoringLevel 10 Y21-1447635 ______________ $37.04 _____________Level 11 Y21-1447639 ______________ $37.04 _____________Level 12 Y21-1447643 ______________ $37.04 _____________Level 13 Y21-1447647 ______________ $37.04 _____________Level 14/15 Y21-1447651 ______________ $37.04 _____________Level 16-18 Y21-1447655 ______________ $37.04 _____________Scoring and Reporting MaterialsScoring KeysThese booklets provide the answer keys for all tests.All Levels Y21-949132 ______________ $39.64 _____________Norms and Score Conversions BookletsAll Levels Y21-949140 ______________ $67.95 _____________Posttest and Support MaterialsInterpretive GuidesAll Levels Y21-949133 ______________ $40.47 _____________Technical ManualAll Levels Y21-949137 ______________ $36.34 _____________Content ObjectivesAll Levels Y21-949125 ______________ $21.41 _____________Report to Students and ParentsLevel 5/6-8 Y21-949143 ______________ $25.00 _____________Level 9/14-15 Y21-949145 ______________ $25.00 _____________Level 16/18 Y21-949147 ______________ $25.00 _____________Subtotal for this pageSubtotal from previous pagesOrder SubtotalState Sales TaxShipping Service Fee*Order Total______________________________________________________________________________3800 Golf Road, Suite 100, Rolling Meadows, IL 60008phone 800-323-9540fax 630-467-7192www.riversidepublishing.com* A shipping service fee is prepaid and added to the invoice. Estimate10% ($10.00 minimum) for ground shipping; 15% ($10.00 minimum)for Second Day Air and shipping to AK and HI; 17% ($20.00 minimum)for Next Day Air shipping; and 25% for international shipments. Groundtransportation available for AK and HI upon request.Prices are valid until December 31, 2010 and are subject to change without notice.