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1MEDICAL EXAMINATION REPORT
ORDER FORM
UTAH TRUCKING ASSOCIATION
4181 W. 2100 S.
West Valley City, Utah 84120
(801) 973-9370
FAX (801) 973-8515
DESCRIPTION
PRICE
QTY
TOTAL
DOT MEDICAL CARDS (25)
[.36]
$ 9.00
DOT MEDICAL CARDS (50)
[.26]
$ 13.00
DOT MEDICAL CARDS (100)
[.20]
$ 20.00
PHYSICAL EXAM FORM/NCR (25)
[.50]
$ 12.50
PHYSICAL EXAM FORM/NCR (50)
[.40]
$ 20.00
PHYSICAL EXAM FORM/NCR (100) [.35]
$ 35.00
** SHIPPING
SUB-TOTAL
25 FORMS & CARDS
$ 4.50
6.85% Sales Tax Rate
50 FORMS & CARDS
$ 5.50
** SHIPPING
100 FORMS & CARDS
$ 8.50
100+ FORMS & CARDS $ 9.50
OUT OF STATE – Call UTA
GRAND TOTAL
PLEASE MAKE CHECK PAYABLE TO:
UTAH TRUCKING ASSOCIATION
4181 W. 2100 S.
West Valley City, UT 84120
COMPANY NAME_________________________________________________
ATTENTION______________________________________________________
PHYSICAL ADDRESS______________________________________________
______________________________________________
______________________________________________
PHONE________________________ FAX _____________________________
□ Visa □ MC □ AMEX
C
C
REDIT
ARD INFORMATION
Number____________________________________________________
Expires_____/_____/_____ Customer Code____________
Authorized by_______________________________________________
PAYMENT REQUIRED WITH ORDER
Word – 05/14 update
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Parent category: Medical