Order/Quote Form

Order & quote form format: Copy and paste this to a word document and adjust to your needs.

Submitted by:
Phone:
Email:
Address:
City/State/Zip:

Item	Description	Size		Color	Quantity	Unit Price	Amount
Item	Description	Case	Singles	Color	Quantity	Unit Price	Amount
Found in Address url	Full Title of product	If Sold by case	If Sold in Singles	If color options	How many?	Blank if quote needed	Total for item
Sample 1083014ea	Proactive Medical Products Fingertip Pulse Oximeter		X	N/A	25	28.85	144.25












	Tax
	Shipping
						Total

Feel free to modify by adding pages:

Notes & Questions:

Credit Card Authorization Form:

Please complete all fields. You may cancel this authorization at any time by contacting us.

Credit Card Information

Card Type: ☐ MasterCard ☐ VISA ☐ Discover ☐ AMEX Other ___________________________________________

Cardholder Name (as shown on card): _________________________________

Card Number: ___________________________________________

Expiration Date (mm/yy): ___________________________________________

Cardholder ZIP Code (from credit card billing address): ___________________

I, _______________________________, authorize __________________________________ to charge my credit card above for agreed upon purchases. I understand that my information will Not be saved to file for future transactions on my account.

Signature____________________________________________________________________________________________