Order/Quote Form
Order & quote form format: Copy and paste this to a word document and adjust to your needs.
Submitted by: |
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Phone: |
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Email: |
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Address: |
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City/State/Zip: |
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Item |
Description |
Size |
Color |
Quantity |
Unit Price |
Amount |
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Case |
Singles |
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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 |
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X |
N/A |
25 |
28.85 |
144.25 |
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Tax |
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Shipping |
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Total |
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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____________________________________________________________________________________________