MEDWEAR DIRECT - UNIFORM ORDER FORM

Bill To: (Must match credit card statement address) Ship To: (if different)
Company: Company:
Name: Name:
Address: Address:
City, City:
State & Zip Code: State
Phone: Zip Code:
Email: Phone:
Item Number Color Size Description Qty Price ea. Total
             
             
             
             
             
             
             
             
             
             
             

Ground Shipping Charges
$6.95 = 1 item
$8.95 - 2 items
$10.95 = 3-5 items
$13.95 - 6 or more items

Sub Total:  
Lines of Embroidery X $5.95 each:  

California Residents add 8.25% Sales Tax:

  
Shipping:
FAX 800-589-1025 / www.medweardirect.com
 Total:  


METHOD OF PAYMENT

Check or money order payable to: MEDWEAR DIRECT

If ordering by Credit Card, please fill in the information below:

VISA Master Card Discover American Express


MAIL TO:

MEDWEAR DIRECT
881 SNEATH LANE, SUITE 113
SAN BRUNO, CA 94066

Or FAX TO: 800-589-1025

CREDIT CARD NUMBER
EXPIRATION DATE
AMOUNT


CVV2 CODE
NAME AS IT APPEARS ON CARD


SIGNATURE DATE