The Dementia Action Plan: 7 Steps to Take in the Face of Dementia

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* 1. Your firm's name? This organization will be considered the Seminar(s) Host.

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* 2. Please provide the Zip Code for the city/town where the seminar(s) will be held. If more than one location, please separate each Zip Code with a comma.

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* 3. Your full name?

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* 4. Your email?

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* 5. Your shipping address?

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* 6. Your best contact phone number?

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* 7. Is this a mobile phone?

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* 8. If other than you: please enter the name, email, and phone number of the person to receive our online invoice and pay it. Order will not ship until payment has been made in full. Thank YOU!

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* 9. When do you need the seminar supplies? Please provide the month, day and year. Please plan ahead and allow 10 business days to process and ship your order. Contact us for rush delivery at 1-800-336-3684 (additional charges may apply).

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* 10. Please confirm: I understand that items I am ordering cannot be returned for credit or refund.

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* 11. How many TDAP DVDs do you need? ($9.95 Value) Only $5.00 each, in any qty. Any applicable taxes and ground shipping included.

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* 12. How many DSA TDAP Streaming Rack Cards with Promo Code to view online (no DVD) do you need? $1.00 each, in any qty. Any applicable taxes and ground shipping included.

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* 13. How many DSA tri-fold "Are You Curious?" Brochures do you need? $1.00 each, in any qty. Any applicable taxes and ground shipping included.

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* 14. How many DSA "Aware & Share" Cards do you need? $1.00 each, in any qty. Any applicable taxes and ground shipping included.

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* 15. How many DSA "We Know You Matter" purple silicone cause bracelets do you need? $1.00 each, in any qty. Any applicable taxes and ground shipping included.

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* 16. Will there be any additional 3rd-party sponsor(s), i.e., an in-home care company, elder law attorney, care community, etc., donating directly to the Dementia Society of America to financially support this seminar(s)? If so, please enter all names, contact phone/email, amount of support. If none, leave blank.

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* 17. Do you have any questions or comments? You may also call us 1-800-DEMENTIA or email admin@dementiasociety.org.

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