Healthcare Materials Order Form printable pdf download

Healthcare Materials Order Form

Assessment Resource Center

Healthcare Materials Order Form

2800 Maguire Blvd.

Columbia, MO 65201

Phone: (800) 366-8232 (573) 882-4694

Fax: (573) 882-8937

MUARCHealthmaterials@missouri.edu

Purchase Order No. _________________

Date ________________

Ship To:

Charge To:

(Please Print)

(If Different from Shipping Address)

Name of Organization

Attention of

Street

City

State

ZIP

City

State

ZIP

Telephone No.

Catalog

Quantity

Item Description

Test Date

Unit Price*

Total Cost

Code

50611

CERTIFIED NURSE ASST -

INSTRUCTOR

$97.59 ea

50612

CERTIFIED NURSE ASST - STUDENT

$36.57 ea

50613

CERTIFIED NURSE ASST - RESPONSE FORM

$17.25 ea

50614

CERTIFIED NURSE ASST - CD-ROM

$195.00 ea

50701

RESTORATIVE NURSE -

INSTRUCTOR

$74.42 ea

50702

RESTORATIVE NURSE - STUDENT

$42.49 ea

60801

INSULIN ADMINISTRATION -

INSTRUCTOR

$17.00 ea

60802

INSULIN ADMINISTRATION - STUDENT

$7.73 ea

60811

VENOUS ACCESS 03’ -

INSTRUCTOR

$95.28 ea

60812

VENOUS ACCESS 03’ - STUDENT

$63.86 ea

60641

CMA MEDICATION AID - LEVEL 1 -

INSTRUCTOR

$40.94 ea

60642

CMA MEDICATION AID - LEVEL 1 - STUDENT

$20.34 ea

Subtotal

*Prices are subject to change.

Sales Tax (if applicable) = 7.975%

Shipping & Handling (10% or $6.00, whichever is greater.)

TOTAL (Minimum $20)

The order form may be sent to the Assessment Resource Center (ARC) by FAX, US mail, or emailed. Methods of pay-

ment: Check made payable to University of Missouri, Visa, MasterCard, Discover, American Express, or Purchase Order.

New

customer—please include copy of W-9. Purchase order payment is due upon receipt of invoice. Credits will not be

issued for materials returned after 30 days.

If you are tax exempt, please provide the tax exempt letter with your order.

Cardholder’s Name: ____________________________________________________ Expiration Date: _____________

(Please print)

Cardholder’s

Number: ____________________________________ CVC #: ______ Signature: ______________________________

10/2 sm

Healthcare Materials Order Form

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