DoctorPromo ORDER FORM

NAME ________________________________________________________________________

ADDRESS ____________________________________________________________________

ADDRESS ____________________________________________________________________

TEL. ______________________________________ FAX ______________________________

EMAIL ADDRESS ______________________________________________________________

VISA MASTERCARD   AMEX  *  DISCOVER    PREPAID BY CHECK

Is card billed to address above?   Yes   No   If no, please enter address:

BILLING ADDRESS ____________________________________________________________________

ADDRES              S ____________________________________________________________________


CARD NUMBER _____________________________________________  EXP. DATE ______________

3 Digit # on Security Panel ________________  *4 Digit # on Front of Card (Amex)_____________

SIGNATURE __________________________________________________________________

ITEM DESCRIPTION

QTY.

PRICE EACH

TOTAL PRICE

       
       
       
       
       
       
       
       
       
       
       
       
       
       
       



PLEASE CALL FOR SHIPPING CHARGES
$8.00 MINIMUM

SUBTOTAL

$
SHIPPING
 $
NY SALES TAX
 $
TOTAL
 $
TERMS AND CONDITIONS
‑ ORDERS MUST BE PAID BY CREDIT CARD OR CHECK IN ADVANCE
‑ NO C.O.D.S
‑ ALL PRICES SUBJECT TO CHANGE WITHOUT NOTICE
‑ NO RETURNS WITHOUT PRIOR AUTHORIZATION
‑ NO RETURNS ON CUSTOM ITEMS
‑ RETURNS ARE SUBJECT TO A 15% RESTOCKING FEE
‑ DOORMATS AND ACRYLIC ITEMS CAN BE RETURNED FOR CREDIT ONLY
‑ SHIPPING AND HANDLING CHARGES WILL BE APPLIED TO ALL ORDERS
‑ NO REFUNDS ON SHIPPING CHARGES
‑ MERCHANDISE IS SHIPPED UPS GROUND UNLESS OTHERWISE REQUESTED
‑ A $30 FEE WILL BE CHARGED FOR RETURNED CHECKS