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Please complete this form & print it, then mail or fax to the address below.
Name______________________________________________
Company___________________________________________
Street Address_______________________________________
City, State, Zip ______________________________________
Phone: ______________________
E-mail (to confirm order only): _____________
ITEM DESCRIPTION: (For dictation orders please be sure to included your preferred media format, i.e. standard or micro tapes, or CD-ROMs.)
Item Details: _______________________________________ Price $_______
Item Details: _______________________________________ Price $_______
Any Details Needed For Order Fulfillment? ___________________________________________________________
___________________________________________________________
SHIPPING FEES: Any Complete Set and Transcript Keys $15. Any Individual Set or Single CD-ROM and Transcript Keys $7.00.
We ship via USPS Priority Mail with Delivery Confirmation.
Your Shipping Fee: $______
GRAND TOTAL: (US dollars only)$____________
PAYMENT OPTIONS: Enclose Check or Money Order with this form via mail, OR Charge to (Circle one) Visa / MasterCard / Discover and mail.
Cardholder Name_____________________________________
Account No. _________________________________________
Expiration Date ___________________
Authorized Signature_______________________________________________
*Please make checks payable to our supplier directly:
HomEx Medical, NOT Medword.
Mail your order to:
HomEx Medical
P.O. Box 637
Hampstead, Maryland 21074
We will confirm receipt of your order via e-mail. Every effort is made to ship within 5 working days of receipt of your order. |
