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HTML Preview Medical Purchase Order Form page number 1.
1
MODEL
QTY
PRODUCT
COLOR
SIZE
UNIT PRICE
TOT
AL PRICE
4MD MEDICAL SOLUTIONS PURChASE ORDER fORM
TOLL FREE
877-463-5818
FA
X
866-611-6999
WEB
WWW
.4MDMEDICAL.COM
EMAIL
[email protected]
Or
ganization:
❑
Check enclosed for: $
❑
This conrms a phone order
Name of Salesperson:
❑
I have order
ed fr
om 4MD Medical before
❑
Notify me before delivery
(may incur additional char
ges)
Phone:
❑
Visa
❑
MasterCard
❑
AMEX
❑
Discover
Name:
Title:
Signature:
Date:
PO #:
❑
Bill us “Net 30 Days”
(call 877-463-5818 for details)
Card #:
Exp. Date:
❑
Pay by credit car
d
(use the form to the right)
Name on Card:
Signature:
Or
ganization:
SOLD TO
P
A
YMENT TYPE
CONfIRMA
TION
Customer Inf
ormation
P
ayment Inf
or
mation
Order Inf
or
mation
ShIP TO
CREDIT CARD INfORMA
TION
AUThORIZA
TION
Attention:
Attention:
Street:
Street:
City:
City:
State:
State:
Zip:
Zip:
Phone:
Phone:
Fax:
Fax:
Email:
When Complete, return with your purchase or
der by fax 866-611-6999 or email
[email protected]
DOWNLOAD HERE
Your most unhappy customers are your greatest source of learning. | Bill Gates