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Customer#: | |
Customer PO#: | |
*Phone #: | |
*E-Mail Address: | |
Dealer: | Dentist: Lab: Other: |
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Bill To: | |
*Name: | |
*Address: | |
*City: | |
State: | |
*Zip: | |
*Country: | |
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Ship To (If different from billing address): |
Name: | |
Address: | |
City: | |
State: | |
Zip: | |
Country: | |
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Ship Via: | |
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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 $10.00 HANDLING FEE. |
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Payment Information: |
*Credit Card: | |
*Card Number: | |
*V-Code (3 digit code on back of MC, Visa ad Discover, and 4 digit code on front of AmEx): | |
*Name on Card: | |
*Expiration Date: | Year: |
I have read and agree with the terms and conditions of sale Agree If you have any questions relating to this form, e-mail us or call toll-free: 1-800-872-8898
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