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Order Form   Use your browser print button to print as many copies as you need          Prescription
 Mail To:
DRSforms-systems.com
24 Imperial Drive
Selden, NY 11784
 Fax to:
    (631) 696-4901
7/24
Office Hours:
Monday - Friday
9:00 AM - 12:30 PM
1:30 PM - 5:30 PM
Eastern Standard Time
Toll Free:
1 (866) 696-0800
Date of Order
  
Customer Name
 
Ship to Address*
  
Ship to City, State, Zip
  
Telephone Number
 
Fax Number
 
E-Mail Address
 
PLEASE SEND ME: (Fill in only boxes that apply)
Product No
Quantity
Description
State
Unit Price
TOTAL
             
             
 
Print clearly or type imprint information on separate sheet and send with this order.

 *Street Address only, No PO Box Numbers

 Samples Enclosed:   Yes___   No___  Copy attached: Yes___   No___  
 Have you ever purchased from DRS before?   Yes___   No___  
 Person to contact about this order: _____________________________________
                          *New York State Sales Tax will be added to NY state residents only.
  MERCHANDISE TOTAL
 
  SHIPPING CHARGE**
 
  TOTAL*
  
**Shipping Charges : 10 Pads $7.50 - 20 Pads $8.50 - 40 Pads $9.50 - 100 Pads $11.50   48 Contiguous states via UPS Ground
*Sales tax will be added to New York State residence only.
Name as it appears on Card
  
Card Number
 
Expiration Date
 
Street Address where billed to
  
Zip Code where billed to
  
Imprint Information sheet Click Here.
   Customer Signature:_________________________________________________________ Date: _______________________
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