QCN Sensor Request Form (Printable)

Billing Information
  Name:     Last:   First:   I:
  Phone:
  E-mail:
  Address 1:
  Address 2:
  City:  State:   Zip: 
  Country:
  Donor Type: Educator:  Public Organization:   Business:
Individual:   Other:
    If teacher, what grades?  K-5:  6-8:  9-12: College+: 
     
Order:
  Quantity:   X $49 =    $
   

Please provide one or more recipient contact below. If you do not provide a recipient contact, QCN will attempt to provide sensors to the nearest school or community center to the zip code and/or state provided. At the moment QCN does NOT ship internationally, but we hope to in the near future. Sensor shipments start in November, 2008.
     
  Payment

Please print this form and make check payable to:

The Quake-Catcher Network
Geophysics Department
Stanford University
397 Panama Mall, Room 360
Stanford, CA 94305
USA
     
Recipient1 1
  Name:     Last:   First:   I:
  Phone:
  E-mail:
  Organization:
  Address 1:
  Address 2:
  City:  State:   Zip: 
  Country:
  Donor Type: Educator:  Public Organization:   Business:
Individual:   Other:
    If teacher, what grades?  K-5:  6-8:  9-12: College+: 
     
Recipient 2
  Name:     Last:   First:   I:
  Phone:
  E-mail:
  Organization:
  Address 1:
  Address 2:
  City:  State:   Zip: 
  Country:
  Donor Type: Educator:  Public Organization:   Business:
Individual:   Other:
    If teacher, what grades?  K-5:  6-8:  9-12: College+: 
     
Recipient 3
  Name:     Last:   First:   I:
  Phone:
  E-mail:
  Organization:
  Address 1:
  Address 2:
  City:  State:   Zip: 
  Country:
  Donor Type: Educator:  Public Organization:   Business:
Individual:   Other:
    If teacher, what grades?  K-5:  6-8:  9-12: College+: 
     
Recipient 4
  Name:     Last:   First:   I:
  Phone:
  E-mail:
  Organization:
  Address 1:
  Address 2:
  City:  State:   Zip: 
  Country:
  Donor Type: Educator:  Public Organization:   Business:
Individual:   Other:
    If teacher, what grades?  K-5:  6-8:  9-12: College+: