Mail or Fax in Your Order
Print out this order form and either:
Fax it to (541) 955-7217
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.
I am enclosing a check or money order for $149 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:
Name on Card:
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.
I authorize The Financial Aid Center for Long Term Care to charge $149.00 USD plus shipping & handling to my credit card for the purchase (and shipment) of the "Medicaid Asset Protection Plan" Video Package.