Name    

Address  

Address  

City       

State          Zip  

Country  

Ship To (If different from billing address):

Name     

Address  

Address  

City       

State            Zip  

Country   

Customer #       Customer PO# 

Phone # 

Fax # 

E-Mail Address 

Dealer National International N/A Dentist Denturist General Ortho Prostho N/A Lab Casting C&B Denture Full Service N/A Other Hospital Patient Pharm. School N/A

Ship Via:  UPS Ground UPS Overnight UPS 2nd Day UPS 3-Day Air Parcel Post Trucker BAX (Burlington Air Freight Other

Item #                        Qty     Description and Shade    US $ Amt.

                                             Merchandise Total:  

All taxes, shipping, and hazardous charges (where applicable) will be added to invoices prior to shipping.  Dealer discounts will be applied as earned.  ORDERS UNDER $50 ARE SUBJECT TO A $5.00 HANDLING FEE.                                                                

Payment Information:

Credit Card Visa Mastercard Discover

Card Number

3 Digit Code (found on back of card)  

Name on Card  

Expiration Date 01 02 03 04 05 06 07 08 09 10 11 12   Year 2008 2009 2010 2011 2012 2013 2014 2015

I have read and agree with the terms and conditions of sale  Agree

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