DEALER ORDER FORM
Fax to: 866.931.0052
Mail to: BiaCare Corporation
Call Toll Free: 866.931.0876
110 W. Washington Ave.
Email to: [email protected]
Zeeland, MI 49464
Dealer Name:
Dealer Number (Optional):
Contact Name:
Phone Number:
P.O. Number:
Fax Number:
Bill to Address:
Ship to Address:
Bill to City:
Bill to State:
Order Date:
Bill to Zip:
Ship to City:
Ship to State: Ship to Zip:
Patient Name (Optional):
Shipping Instructions (Optional):
ITEM NUMBER
PRODUCT DESCRIPTION
QTY
PRICE
TOTAL
(less S&H)
84
TOTAL