The Neuro Letterhead Order Form
Montreal Neurological Institute and Hospital
* Denotes required entry
* Contact Full Name:		* Phone/Local#
		* Email Address
* McGill FOAPAL number or MUHC Cost Centre number:
Please select requirements:    Electronic File letterhead word template:    Preprinted- $120.00 / 500 sheets X

Please enter all header information below for the Letterhead. * Name (First & Last Name): Example: Dr. John Smith or John Smith, MD, PhD                         (Enter French Version Below- en francais) * titre * departement (Enter English Version Below) * Title * Department         Please enter the phone, fax locals and Email Address for letterhead footer NOTE: Phone Extension, Fax number and the email address are optional entries Institut et hôpital neurologiques de Montréal 3801, rue University, Bur: Montréal (Quebec) H3A 2B4 T.514.398.* Ext. F.514.398. Email: leneuro.com Montreal Neurological Institute and Hospital 3801 University Street, Montreal, Rm ###, Quebec H3A 2B4 T.514.398.XXXX Ext. XXXXXXXX F.514.398.XXXX Email: Someone.mni@mcgill.ca   theneuro.com For security reasons, please enter the characters in the image into the text box below.