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
_______________________________________________________________
NAME

_______________________________________________________________

ADDRESSSTREET ADDRESS ONLY - NO P.O. BOXES
_______________________________________________________________
ADDRESSRURAL ROUTE CUSTOMERS PLEASE PROVIDE KEY STREETS OR DIRECTIONS
_______________________________________________________________________
address  

3. SHIP TO: If different from information above.
_______________________________________________________________
NAME
_______________________________________________________________
ADDRESS STREET ADDRESS ONLY - NO P.O. BOXES
_______________________________________________________________
ADDRESSRURAL ROUTE CUSTOMERS PLEASE PROVIDE KEY STREETS OR DIRECTIONS
_______________________________________________________________
address  

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
_______________________________________________________________
NAME AS IT APPEARS ON CARD
_______________________________________________________________
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