2932 Ruger Drive, Suite# B, Royse City, Texas 75189
CN A Tel: 972-961-4655 Fax: 469-721-7000
MEDICAL www.cnamedical.com FILL OUT, PRINT & FAX
Customer Reference / Shipping Information P.O.#:
Bill To: Ship To:
City: State: City: State:
Zip Code: Country: Zip Code: Country:
Method of Payment
Wire Transfer (+$37.50 fee) Credit Card (+3% handling fee Visa Money Order Cashier's Check
& Mastercard / 4% American Express)
Partial shipments will incur extra freight charges.
Credit Card Orders Cardholder's Signature:
Account #: Expiration Date:
Cardholder's Name: 3 or 4-Digit Verification Code on Card:
Billing Address of the Card:
Phone Number to Which the Card is Registered:
For security reasons, please fax in a copy of the front and back of your credit card, making sure the back is signed and
the signature matches that on this purchase order. Please also fax in a copy of your driver's license. This information
will be used to verify the validity of your account. If we are unable to verify your account (some banks do not allow verification)
or your order is over $2,000, we must receive your payment by one of our other methods.
Our shipping carrier is DHL.
If you choose to have the order shipped on your account, please provide us with your FedEX or DHL account number.
Your account number: __________________________ DHL Other carrier: ____________ (+$25 service fee)
For products not in our stock: All orders from the manufacturer to us will be shipped Ground unless
otherwise requested. All orders from us to you will be shipped Ground or least expensive (slowest) method
unless otherwise requested. Expedited shipping will incur additional freight charges.
Manufacturer Item Number Measure Item Description Quantity Unit Price Sub-Total
For CNA Medical Use Only Freight & Insurance
For CNA Medical Use Only Wire or Handling Fee (if applicable)
For CNA Medical Use Only Total