LOAN REQUEST FORM

To request the loan of a copy of the book about Dr. Peter J. Jannetta and MVD, "Working in a Very Small Place: The Making of a Neurosurgeon", by Mark L. Shelton, please complete the form below and follow the instructions.

(PLEASE PRINT or TYPE)

Name: _________________________________________________________________

Street Address: ___________________________________________ Apt./Ste.: _____

City: _________________________ State/Province: _________________

Country: ____________________ ZIP Code: _________________

Email Address: ___________________________

Telephone Number: (____) ________________

Refundable Deposit Amount:             $ 20.00 (USD)

(NOTE: After reading the book you will be asked to mail it, at your expense, to the next member on the list. When we are notified that the book has been received by that member, your $20.00 deposit will be refunded to you.

Payment Method in USD:

(Check one.) PayPal®: _______ Check/Money Order: _______

Ordering Instructions for submitting refundable deposit with PayPal® (funds in USD):

  1. Click on the following link to open up the Loan Request e-mail Form.
  2. Copy the above section of the form and paste it into the "Loan Request e-mail Form".
  3. Send the e-mail
  4. To send your $20.00 USD refundable deposit, click on the following link to get to our Contribute to the HFSA page and follow the PayPal® directions detailed there. (NO CREDIT CARD PAYMENTS ACCEPTED)
  5. You’re finished and as soon as the funds are received the book will be mailed.

(NOTE: If you prefer not to submit via e-mail, print out the form, complete it and mail it to the address listed below; however, you may still submit the payment via PayPal®. Also, as long as you provide your full mailing address and telephone number in your PayPal® payment, you may disregard the form completely)

 

Ordering Instructions for submitting refundable deposit with Check or Money Order (funds in USD):

  1. Print out this page.
  2. Complete the above section
  3. Mail completed form with your $20.00 refundable deposit check/money order (USD), made payable to HFSA to:

           Jack O'Donnell,  Treasurer
           HFSA
           3345 Kenmore Drive
           Sarasota, FL 34231-7131

           (Please allow 3-4 weeks for delivery via U.S. Mail.)