Order Form Template printable pdf download

Order Form Template

ORDER FORM

UPC MEDICAL SUPPLIES, INC.

317 S. San Marino Avenue, San Gabriel, CA 91776 U.S.A

Order Desk: (800)790-4888 Info: (626)285-1600 Fax: (888)460-7269 (626)285-0061

e-mail: upc168@sbcglobal.net

Bill To:

Ship To:

Name:________________________________ Name:_________________________________________

Company: _____________________________ Company: ______________________________________

Address: ______________________________ Address: _______________________________________

Suite / Apt. No. ________________________ Suite / Apt. No.__________________________________

City, State, Zip: ________________________ City, State, ZIP: _________________________________

Phone: (

) ___________________________ Phone: (

) ____________________________________

Fax: (

) _____________________________ Fax: (

) _____________________________________

Email address: _________________________

PURCHASE ORDER NUMER: ___________

ITEM #

PRODUCT DESCRIPTION

QUANTITY

AMOUNT

Subtotal:

California Sales Tax: __________

Shipping: ___________________

Total: ______________________

Visa / Master Card

American Express

Discover

Card # _____________________________Expiration Date ______________ CVT Code _____

Name on Card _______________________

Card Holder’s Billing Address:

Street __________________________________

City ________State _______ Zip ____________

Signature of Card Holder ______________________________________

We appreciate your business.

Order Form Template