Mail or Fax in Your Order
Print out this order form
and either:
  1. Fax it to (541) 955-7217
  2. Mail it to:
    The Financial Aid Center
    P.O. Box 2200
    Grants Pass, OR 97528

Your Video Package will be sent within one business day of receiving your order. We offer three different shipping options below.

For your convenience and protection, you can fill this form out and print it without transferring any information over the internet. Please fill out the form on your screen and hit the print button at the bottom when complete. Please be sure to accurately fill in all the required fields. Since this information cannot be sent over the internet, we will not be able to check for completeness.

MAPPTM Order Form:
Yes! I would like to order, for a one-time payment of $297 (plus shipping & handling) the Medicaid Asset Protection Plan (MAPPTM) DRA Video Package, including specific information for every state, which will allow me to immediately begin protecting family assets from Medicaid. I understand that after viewing the videos, I can call toll-free 1-866-334-2243 and discuss my situation with an experienced Medicaid expert, free of charge. I also understand that if, for whatever reason, I decide to return my MAPPTM Video Package within 90 days, I will receive an immediate refund -- no questions asked.
Shipping & Handling Options
$14.95UPS Ground (physical address only-no PO Box) $311.95 Total click here to see delivery map
$55.00Special Shipping UPS Next Business Day Afternoon where available, (physical address only-no PO Box) $352.00 Total
Select STATE Where Patient
Will Most Likely Apply For Medicaid:
REQUIRED-> 
Video Format:
DVD 2 Disks
Enter Your Customer Information:
First Name:
Last Name:
Email:
Day Phone:
Evening Phone:
Enter Your Shipping Address
Address:
Physical address
No P.O. Box

City:
State:
Zip:

I am enclosing a check or money order for $297 USD plus shipping & handling. Please note that we do not accept checks by fax, so if you are paying by check you must mail it in.


I want to charge this purchase to my Credit Card.

Enter Your Credit Card Information:
Card Type: Visa
MasterCard
Discover
American Express
Card Number:
Name on Card:
Expiration Date:   
CVV2: See examples below for more information.
On VISA, MASTERCARD and DISCOVER this is a 3 digit number in the signature area on the back of the card. \(it is the last 3 digits AFTER the credit card number\).
On AMERICAN EXPRESS cards, this is a 4 digit number printed above and to the right of the card number on the front of the card.
Enter Your Billing Address
Check here if your credit card billing address is the same as your shipping address and leave the following section blank.
Address:

City:
State:
Zip:
I authorize The Financial Aid Center for Long Term Care to charge $297.00 USD plus shipping & handling to my credit card for the purchase (and shipment) of the "Medicaid Asset Protection Plan" Video Package.

Signature:  _______________________________________