We accept
MasterCard - Visa
American Express - Discover
Secure Prescription Pads
Order Form   Use your browser print button to print as many copies as you need   
 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)
Prescription Pads for (State):
Quantity of Pads
Description
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: _____________________________________
  MERCHANDISE TOTAL
 
10% Discount
1st order only
  
Discounted Total
 
  SHIPPING CHARGE**
 
  TOTAL
  
Credit Card Information    **Shipping charges will be added to your credit card.
Name as it appears on Card
  
Card Number
 
Expiration Date
 
Street Address where billed to
  
Zip Code where billed to
  

   Customer Signature:_________________________________________________________

Date: _______________________

  
Click Here For
Imprint Information Sheet
Mail with imprint information to
DRS Forms
24 Imperial Drive
Selden, NY 1 1784
Fax with imprint information to
1-631-696-4901
7/24
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