Canadian Injured Workers Alliance Resource Order Form

Please print this order form and mail or fax it to us at:

The Canadian Injured Workers Alliance:
1201 Jasper Drive
Thunder Bay, Ontario
Canada
P7B 6R2
Phone: 807-345-3429/Toll Free: 1-877-787-7010
FAX: 807-344-8683
Email: ciwa@vianet.ca


Please fill the table below with information about your order:

Title:

Price:

Quantity:

Total price:

 

      

 

      

 

      

 

      

 

      
 

Grand Total:

  

Please fill the table below with information about yourself:

Name:

  

Address:

  

City:

  

Province/State:

  

Postal/Zip Code:

  

Phone Number:

  

Email Address:

  

Date:

  

Please indicate with an 'X' how you will be paying and if a reciept or invoice is required:

Cash _____

Cheque or Money Order _____

Reciept? _____

Invoice? _____

Thank you for placing an order. Your products should arrive in a few weeks.
If there is any problem with your order, we will contact you.