"Ultrasound Supply ORDER FORM Fax to Imaging Concepts (804)"
Ultrasound Supply ORDER FORM Order Date Fax to: Imaging Concepts (804) 755-8711 #1 Qty U/M Part Number Description Price Ext What Items Would You Like to Order? #2 Customer ID Number #3 Purchase Order Number Cust.ID PO No. If known If required #4 Current ACCOUNT NAME customers Bill To Address: Ship To Address (if different than Bill To): include only account name. If multiple ship to addresses include street address for ship to location. #5 Who Do Contact Name Phone Number We Call w/ Questions? #6 Shipping Instructions: (check one) (freight charges will be added to your invoice) #7 Payment Terms: BILL ME Net 30 Days existing customers How How Would UPS Ground Would CHARGE TO CREDIT CARD You Like You Like UPS Blue (2-Day) Your To Pay? UPS Orange (3-Day) Card No: Order UPS Red (Overnight) Expiration Date: Shipped? Name on Card: Other (Specify) Signature: Imaging Concepts, Inc. • 1-800-228-0060 • Page 49 •