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 •