Meducate Gastroenterology Brochures

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Date of Order:____________

Do you want your Brochures Personalized? Yes No

200 Grandview Avenue
Camp Hill, PA 17011-1706
Phone: 1-800-451-5797
Fax: 717-761-0216
info@meducate.com

Ship to: (no Post Office Boxes)		Bill to: (If Different from Ship To)
Facility		Facility
Address		Address
City		City
State	Zip	State	Zip
Phone		Phone
Fax		Fax
Contact		Contact
Email		Email

Method of Payment:
Bill - Net 30 Days	Charge to my Credit Card:
P.O. #: ______________________	VISA Mastercard
(P.O. # necessary to bill account)	Card #: ___________________________
	Exp. Date: _________________________
Check or Money Order enclosed for $ __________	Signature: _________________________
(No Currency)

Item Number	Description	Quantity	Unit Price	Total











Total Merchandise
Shipping: 7% of Total Merchandise (min $7.50)
Additional Shipping for Displays and/or Residential Address (call for info)
Subtotal
PA sales tax 6% of Subtotal (if applicable)
CA sales tax per county (if applicable)
Total
Personalized order, please mail or fax lettrhead or typewritten personalization. One time set up fee of $50.00 * Personalization change is $50.00.