# Celebrate the Stages!
## Utah Statewide ASQ Screening Initiative

### Order Form

For product information, sample questionnaires and other support resources, visit [http://agesandstages.com/ut/](/content/ut/index.html). Prices valid through December 31, 2025.

| Stock # | Product Name | Unit Cost | Qty | Ext Price |
| --- | --- | --- | --- | --- |
| 70410 | ASQ-3 English Starter Kit | $265.50 |  |  |
| 70038 | ASQ-3 Spanish Questionnaires | $216.00 |  |  |
| 72469 | ASQ-3 Learning Activities | $44.96 |  |  |
| 72476 | ASQ-3 Learning Activities in Spanish | $44.96 |  |  |
| 70274 | ASQ-3 Materials Kit | $265.50 |  |  |
| 79611 | ASQ:SE-2 English Starter Kit | $265.50 |  |  |
| 79574 | ASQ:SE-2 Spanish Questionnaires | $216.00 |  |  |
| 69780 | ASQ:SE-2 Learning Activities & More | $44.96 |  |  |
| 52735 | ASQ:SE-2 Learning Activities & More in Spanish | $44.96 |  |  |
| 52643 | ASQ-3 Arabic Questionnaires | $157.50 |  |  |
| 53640 | ASQ:SE-2 Arabic Questionnaires | $157.50 |  |  |
| 51820 | ASQ-3 French Questionnaires | $157.50 |  |  |
| 53268 | ASQ:SE-2 French Questionnaires | $157.50 |  |  |
| 52650 | ASQ-3 Vietnamese Questionnaires | $157.50 |  |  |
| 53367 | ASQ-3 Chinese Questionnaires | $157.50 |  |  |
| SUBTOTAL |  |  |  |  |
| Shipping at 10% of subtotal |  |  |  |  |
| TOTAL |  |  |  |  |

Reference list code UTASQ2025 to receive the discounted pricing and shipping shown above.

### Customer Information
- Name: ____  
- Organization: ____  
- Address: ____  
- City: ____  
- State: ____  
- Zip: ____  
- Tel: ____  
- Email: ____

### 3 Ways to Order from Brookes Publishing:
1. **Toll Free:** 800-638-3775 (Customer Service) (credit card orders only)
   - Credit Card Number: ____  
   - Exp Date: ____  
   - SIC: ____  
2. **Fax:** 410-337-8539 (credit cards or purchase orders)
   - Purchase Order #: __________________________ (must include/attach a copy of the P.O.)