Order By Mail

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1. PHONE: In case we have questions about your order.
Daytime	()_________________	Fax	()_________________
Evening	()_________________	E-mail	_____________________

2. ORDERED BY:

Is this being delivered to: HOME/RESIDENCE BUSINESS/OFFICE

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NAME

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ADDRESS

STREET ADDRESS ONLY - NO P.O. BOXES

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ADDRESS

RURAL ROUTE CUSTOMERS PLEASE PROVIDE KEY STREETS OR DIRECTIONS

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3. SHIP TO: If different from information above.

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NAME

_______________________________________________________________

ADDRESS

STREET ADDRESS ONLY - NO P.O. BOXES

_______________________________________________________________

ADDRESS

RURAL ROUTE CUSTOMERS PLEASE PROVIDE KEY STREETS OR DIRECTIONS

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4. METHOD OF PAYMENT

Check or money order enclosed. Please make payable to:
Medical Scrubs
Credit Card If ordering by credit card, please fill in the following information:

CREDIT CARD NUMBER		EXPIRATION DATE
Visa MasterCard and Discover Security Code It is the 3 digit, non-embossed number printed on the signature panel on the back of the card	American Express Security Code It is the 4 digit, non-embossed number printed above your account number on the front of the card	SECURITY

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NAME AS IT APPEARS ON CARD

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SIGNATURE

STYLE NUMBER	COLOR	SIZE(S)	QTY	ITEM DESCRIPTION	PRICE EACH	TOTAL














				TOTAL PURCHASE
				EXPRESS SERVICE NEXT DAY AIR: Add $19.50 2nd DAY AIR ADD $12.00
				SHIPPING AND HANDLING
				8.25% Sales Tax CALIFORNIA RESIDENTS ONLY
				ORDER TOTAL

SHIPPING AND HANDLING
ORDER TOTALS	ADD
$0 - $20.00	$5.99
$21.00 - $40.00	$8.99
$41.00 - $80.00	$11.99
$81.00 and up	FREE

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