| Bill To:______________ | Ship To:______________ |
|---|---|
| ____________________ | _____________________ |
| ____________________ | _____________________ |
| Phone:______________ | Phone:_______________ |
| Please send a catalog to:____________________________ | |
| Product # | Quantity | Description | Unit Price | Total Price |
|---|---|---|---|---|
| Subtotal: _______ | |
| Shipping (See Chart Below): _______ | |
| Tax Exempt#____________________MI Residents Add 6% Sales Tax: _______ | |
| Total: _______ | |
| Visa/MC#: ____________________________Expir. Date: _______ | |
| Buyer's Signature: _______________________Date: _______ |
| Phone: | Credit card orders may be phoned om between 8 a.m. and
4 p.m. Monday-Thursday, or 8 a.m. amd 2 p.m. on Friday's.
EST
Phone: 1-800-000-0000 or 1-800-000-0000 |
| Mail: | Send signed purchase order or completed order form with a check,
money order, or your Visa/MC number and expiration date to:
Therapy Solutions, P.O. Box 0000, Grand Rapids, MI 49506 |
| Fax: | Fax order form on an official/signed purchase order, or with your
Visa/MC number and expiration date--24 hours/7 days a week.
Fax: 1-800-000-0000 |
| Shipping Charges*: | Up to $25.00
$25.00-$35.00 $35.00-$50.00 $50.00-$100.00 Orders over $100.00 |
Add $4.75
Add $5.95 Add $6.95 Add $7.95 Add 10% |
*Shipping charges apply to continental United States only--Alaska, Hawaii, and Canada are excluded. Please call for international shipping rates/information.
