KW-Med Quick Order Form 2008

Thank you for your order!

Please complete and Submit the form below.

Your facility will receive either an email or phone confirmation within 1 business day.

Note: An asterisk (*) indicates the information is required for order to be processed.

*Contact Name:

*Contact e-mail:

*Contact phone:

Please enter Customer Billing Information below:

**Note: The facility name and address information are not required when a current Customer Account Number is submitted below.

**Customer Acct No: (Contact Customer Service to obtain or confirm)

**Facility Name:

**Address:

**City: State: Zip:

Please enter Shipping Information — If different from above:

Ship-to Name:

Address:

City: State: Zip:

Product Purchase Information:

Purchase Order No: (Optional)

Payment Method:Pay Terms per KW-MED ACCOUNT Profile

Credit Card: Visa, MC, AmEx, Discover

(Customer Service will verify - Credit card info. will be collected by phone or fax only)

Shipping Method:

Product Information:

Quantity Description and/or Part Number

* Item 01

Item 02

Item 03

Item 04

Item 05

Item 06

Item 07

Item 08

Item 09

Item 10

Please enter any comments or questions below:

Comments or Questions:

1) Before submitting, please print a copy of this page for your records.

You may also print & fax the order.

2) When applicable, Credit Card information will only be obtained via phone or fax.

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