Material Purchase Order Form - Excel by gbv55602

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									                                                                  Wal-Mart Stores, Inc
                                                   First Aid, CPR Equipment & Materials Order Form



                                                                                Contact
Facility Name:                                                                  Name:
Ship to Facility?? Yes / No                                                     Will Pickup Yes / No
Shipping                                                                        City:                              St:               Zip:
Address:
Billing Address:                                                                City:                              St:               Zip:
(if different)
                                         Fax                                                 Payment Method: Due upon pick-up
Phone:                                   :                                                  Cash        Check       AMX     Discover
Instructor                                                                                  Invoice         PO Number:
Name:                                                                                       Visa            MasterCard
Email                                    Name of                                Acct #:
Address:                                 Course:                                  Exp:                      3-Digit Code:
Today's                                  Date                                   Ship                                     Shipped
Date:                                    Needed:                                Date:                                    by:

Material Purchase: Each Student must have their own set of training materials.
              Training Materials                                                           Stock           Price          Num            Total
                                                                                          Number                          Req

                                                   "X" Indicates
                                                                    CPR/AED
                                                                    First Aid



                                                   Required
                                                   Training
                                                   Materials
  First Aid/CPR/AED Participant's Manual                                X                 656731            $8.50                    $        -
  Adult First Aid/CPR/AED Ready Reference Card                          X                 656732            $2.95                    $        -
  Pediatric First Aid/CPR/AED Ready Reference Card                      X                 656733            $2.95                    $        -
  First Aid/CPR/AED DVD                                                 X                 656735          $174.95                    $        -
  First Aid/CPR/AED Instructor's Manual                                 X                 656730           $49.95                    $        -
  Conscious Choking Skill Poster                                        X                 656736            $6.95                    $        -
  Splinting Skill Poster                                                X                 656729            $6.95                    $        -
  First Aid Training Pack                            (for FA)           X                 WN1200            $3.00                    $        -
  CPR Skill Poster                                                                        656737            $6.95                    $        -
  Checking an injured or Ill Adult, Child, or Infant Skill Poster                         656734            $6.95                    $        -
  First Aid/CPR/AED Instructor Manual                                                     656730           $49.95                    $        -
                                                                                                                                     $        -
                                                                                                                                     $        -
        Supplies & Equipment
  ACTAR D-fib Lungs (50/pk)                                                               AA-1312     $       40.00                  $        -
  ACTAR 911 Lungs (100/pk)                                                                AA-1812     $       65.00                  $        -
  ACTAR D-fib Manikins (5/pk) call for current price                                      AA-1305                                    $        -
  ACTAR D-fib Manikins (10/pk) call for current price                                     AA-1300                                    $        -
  Bloodborne Pathogens: Preventing Disease Transmission                                   655107      $        2.00                  $        -
  Breathing Barriers (1 Box) (50pk)                                                       151201      $       13.00                  $        -
  FA/CPR/AED Instructor Manual                                                            656693      $       24.00                  $        -
  Manikin Wipes (1 Box) (50/pk)                                                           152401      $       13.00                  $        -
                                                                                                                                     $        -
                                                                                                                                     $        -
                                                                                                                                     $        -
                                                                                                                                     $        -
                                                                                                                                     $        -
                                                                                                                                     $        -
                                                                                                                                     $        -
  American Red Cross Instructor's Name Badge                                              Style #2    $       15.00                  $        -
                                                                                                                                     $        -
Shipping Charges for materials (minimum $10.00)                                                       $       10.00       1.00       $      10.00
  AP Fee (changed 1/1/2009)                                                                           $        8.00                  $        -
                                                                                                                                     $        -

                                                                                                                            Total:
                                                                                    5/29/2009 jwb
Please give a minimum of two weeks notice on all orders to ensure availability of all requested items.
                                                                                            Email: health&safety@redcrossnwa.org
Signature:                                                                                  Phone: 479-306-4688          Fax: 479-306-4325

								
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