Xodus Medical Custom Order Form
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1
2Large Labels 10/ sheet
Xodus Medical Custom Order Form
Fax: 724-337-0555
For multiple sheets Xerox this form.
Please fill out all contact information below. Design your custom labels on the second sheet & fax both sheets to:
(724)337-0555. For multiple sheets Xerox the second page of this order form.
Contact Information
Date:
Company Name:
Contact Name:
Title:
Dept:
Fax #:
Phone #:
Shipping Address:
Attn:
Street:
City, State, Zip
Billing Address:
Attn:
Street:
City, State, Zip
Estimated Usage:
Please create a username below and provide your e-mail address. We will
assign you a password and e-mail it to you so you can access your labels
online if you choose to.
User Name:
E-mail address:
Package Name:
Please fax both forms back to Xodus Medical at 724-337-0555
For questions call 1-800-963-8776
Rev. 4; 4/19/07
1
F060-2 Large Label Order Form
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Parent category: Business