NO._____________
DATE:______________
QTY ORDERED______ SIZE_______ @$________ =AMT. DUE $___________
+ SHIPPING $_________=TOTAL$_______________
P.O. NO.____________
FOR (Hospital)__________________________________________________
(Address)______________________________________________________
(City/State/Zip)_________________________________________________
CONTACT PERSON:_______________________________________________
DEPT._____________________ PHONE NO.___________________________
PURCHASING CONTACT:___________________ PHONE NO.______________
FAX NO.________________________
BILL TO________________________
________________________
________________________
FOR YOU ORDERING CONVENIENCE THIS FORM MAY BE:
MAILED TO: Wright Products, Inc. P.O. Box 51, Decatur, IL, 62525
PHONED TO: 800-356-6911
FAXED TO: (217) 423-7282
EMAIL: GWSLIPP@AOL.COM WWW.WRIGHTPRODUCTSINC.COM