CONTACT INFORMATION OR
BILL TO ADDRESS:
First Name

Last Name
                                
Organization                              
Department 

Street Address

Room Number/Mail Stop

City

State

Country

Zip Code


      
PO NUMBER:
Request Vendor Setup & Tax Id Information
 for your Institution's Purchasing Department
Request Order Confirmation by Fax

PURCHASING  DEPARTMENT CONTACT INFORMATION:
Contact Name 
Purchasing Dept Telephone
                         Facsimile  

Terms Offered U.S. Health Care
 Organizations, n 30 days
NEW CUSTOMER SETUP AND APPROVAL:  IMMEDIATE
We also accept U.S. Government 
& U.S. Commercial Purchase Cards:

Visa  Mastercard  American Express

Credit Card Number:

Expiration Date:

Name appearing on card:

(CREDIT CARD INFORMATION CAN BE ACCEPTED BY TELEPHONE:  800 358 6866 OR 214 995 1132)

Request Brochure & Pricing 
Request Pricing & Transportation Cost
 Estimate for International Destinations

ORDERING INFORMATION*:
Required delivery date:    
  Freight:  prepay & add
Delivery:  Ground; Overnight
Customer Air Carrier Account #
Carrier Name:

Customer Account Number:

Casing Scientific Catalog Numbers:
* All international sales subject to acceptance

   (All Label Purchases are sold by the box)
Catalog No.
Cases Boxes       
Catalog No.
Cases Boxes   
Catalog No.
Cases Boxes   
Catalog No. 
Cases Boxes   
Catalog No.
Cases Boxes   
Catalog No.
Cases Boxes   

When this form is completed, it can be submitted by pressing the "Submit" button at the top of this page, or printed and faxed to 888 661 9606.

Work Phone
 
Extension  
 
Cell Phone (optional)

Facsimile

Email Address


SHIP TO ADDRESS: 
Attention:
Mr. Ms.  
First Name

Last Name

Title

Organization                              
Department
Street Address

Room Number/Mail Stop

City

State

Country

Zip Code

COMMENTS OR QUESTIONS:                                 
ORDERING CONTINUED