Legislative Bill Room Order Form (Official Medical Fee Schedule (OMFS))

State of California--State and Consumer Services Agency Department of General Services LEGISLATIVE BILL ROOM ORDER FORM GS 2055 (New 3/04) THE LEGISLATIVE BILL ROOM STATE CAPITOL, RM B-32 Sacramento, CA 95814 (916) (916) (FAX) Office Hours ­ Monday thru Friday, 8:00 a.m. to 5:00 p.m. ORDERING INSTRUCTIONS: Fill out the GS 2055 order form completely. Orders not properly completed will be returned. If you submit an order, do NOT resubmit. Turn around time on your order is 7 to 10 working days after receipt of the order. The Bill Room will not be responsible for duplicate orders submitted. Back-ordered items will be shipped when available. DUPLICATE ORDERS: Unless the error is on the part of the Bill Room, duplicate orders will be charged. WALK-IN ORDER HOURS: 8 A.M. TO Noon and 1:00 to 3:30 P.M. (Monday-Friday) NOTE: Prices are subject to change without notice. All Personal Checks should include Drivers License # or ID #, with expiration date, and your full birth name. Please make check or money order payable to: The Legislative Bill Room. Mail Order Form to: The Legislative Bill Room, State Capitol, Rm. B-32, Sacramento, CA 95814 SHIP TO: (No P.O. Boxes) Officer Authorizing Expenditure Order Date Please Print or Type Officer's Name Contact Person Contact's EMAIL Address Telephone Number ( ) Description 1 Official Medical Fee Schedule 2 3 4 5 6 7 8 9 10 Payment Method: (Check One) _____ Check _____ Money Order Unit of Measure Price per Unit $45.00 Qty Ordered Total Price Each Note: Sales price includes shipping and sales tax. Subtotal: Total Amount Due: American LegalNet, Inc. www.FormsWorkFlow.com