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

Case

Singles

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____________________________________________________________________________________________