PURCHASE ORDER #:
NAME OF FACILITY ORDERING:
NAME OF PERSON ORDERING:
PHONE: FAX:
EMAIL:

SHIP TO:
NAME OF FACILITY ORDERING:
STREET:
CITY: STATE: ZIP:

WOUNDSTICK MEASURING SYSTEM ORDER:

PART #	DESCRIPTION	QUANTITY - PACK/CASE	PRICE PER	TOTAL

SHIPPING: ______________ (TO BE FILLED OUT BY USMS, INC REPRESENTATIVE)
TOTAL PRICE: $__________ (TO BE FILLED OUT BY USMS, INC REPRESENTATIVE)
Products will be shipped via Priority Mail or UPS. Freight charge will be added.

USMS will bill "on account". Please provide billing address if different from above shipping address.
NAME:
STREET:
CITY: STATE: ZIP:

We accept VISA, MASTERCARD: (circle credit card type used)
NAME OF CARDHOLDER:
CARD NUMBER:
EXPIRATION DATE ON CARD:

SIGNATURE:_____________________________________________________________

USMS billing information: Process Date: _______________ Approval #: _________________

                                                                     

                                                         Thank you for your order