Contraceptive Order Form

This form is designed to be completed, printed and posted/faxed with payment or contact FPQ 07 3250 0240.

Post: Family Planning Queensland, PO Box 215, Fortitude Valley, Qld 4006
ABN 61 009 860 164
Fax: 07 3250 0296

Date:
Contact Name:
Organisation: (If applicable)
street Address:
Phone:		Mobile:
Fax:		Email:
Please do not retain my details for FPQ mail-outs
Privacy policy

Ansell Condoms:		Price	No. Required
	Chekmate 12’s	$10.00
	Lifestyles Form Fitting 12’s	$7.50
	Checkmate bulk box 144 Non-Lubricated Lubricated	$30.00
other Condoms:		Price	No. Required
	Female Condom (3 pack)	$14.00
Diaphragm (please select type and size):		Price	No. Required
	Arcing Spring 65 70 75 80	$85.00
Protection Kits:		Price	No. Required
	Dental Dams	$1.00
	100g flip top tube, plain	$6.00
	270g pump bottle, plain	$9.00
other items		Price	NO. REQUIRED
	Foam penis model	$8.00
*TOTAL VALUE of this order*		Price.	price
	Items
	Postage $35 and under, postage within Australia is $5. Over $35, postage within Australia is $5 + 5% of order
	TOTAL

	Price includes GST. International freight must be prepaid. Contact FPQ by fax or email to check cost
Paying by:	Cheque for $ enclosed
	Order Number: Please invoice (Company Purchase order should accompany this form)
Credit Card	Visa	Mastercard
	Credit Card Number:		3 digit security no. (shown on back of credit card):
	Name on card:		Expiry date :
	Please debit: $ Signature:__________________________________________________
Office Use: Purchasing Date:___________ Int:_____ Accounts Date:___________ Int:_____