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Order Form   Use your browser print button to print as many copies as you need   HIPAA Forms
 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
No of Parts
  
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 is 8% of Merchandise Total . Minimum $8.00. UPS Ground Shipping to 48 Contiguous States
Imprint Information
Line 1  
Line 2  
Line 3  
Line 4  
Line 5  
Line 6  
Line 7  
Privacy Officer
 
Effective Date
 
Credit Card Information
Name as it appears on Card
  
Card Number
 
Expiration Date
 
Street Address where billed to
  
Zip Code where billed to
  
   Customer Signature:_________________________________________________________ Date: _______________________
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