Order form - Henry Schein

[Pages:1]order form

Purchase Order Number: ______________________________

BILL TO (IF DIFFERENT FROM SHIP TO)

______________________________________ ______________________________________ ______________________________________ ______________________________________

Date:____________________________________________________

SHIP TO (WE CANNOT DELIVER TO PO BOXES)

__________________________________ __________________________________ __________________________________ __________________________________

Telephone # Is this your first order: J Yes J No

Your Customer Number:

(

) ______________________________________________

__________________________

Quantity

Order No.

Description

For Internal Use Only

Unit Price

Total Price

Freight ? please call for price quote.

Add applicable state and/or local sales tax. If you are tax exempt, please enclose a copy of your tax exempt certificate.

FREIGHT

SALES TAX IF APPLICABLE

J Please send me a Catalog

$30.00 Minimum Required

TOTAL

METHOD OF PAYMENT

J Check or Money Order

J MasterCard

J VISA

J American Express

J Discover

J Net 30 Days on Pre-Approved Credit ? Application must accompany order.

PLEASE CHECK TYPE OF ORGANIZATION

J Volunteer

J Tax Supported

J Private Business

J Corporation

J Non-profit J Private Individual

J Institution J Other (specify)

TERMS OF SALE: Net 30 days for customers with pre-approved credit. All invoices must be paid in U.S. dollars. Delinquent accounts will be subject to finance charges and other applicable fees. Minimum Order amount $30.00 SHIPPING: All cash sales must include tax (if applicable) and freight, or order will not be shipped. CATALOG PRICES: Pricing and product availability subject to change without prior notice. Prices in effect when your order is received will be honored even if the items are temporarily out of stock. DELIVERY: To provide you with quality service, we stock most high volume products and accessories for shipment within 24 hours. Most orders are shipped via U.P.S. (United Parcel Service). We also use Parcel Post and surface freight where appropriate. We ask our customers to wait at least 14 days before requesting a shipping tracer on their orders. RETURNED GOODS: Please see page 132 for the Matrx Returned Goods Policy.

If you have not received your order within 14 days and have received your invoice, you can help by examining your invoice to find the date and method of shipment. Notify us immediately if the ship-to address on your invoice is incorrect. Of course, we will be happy to help you in any way possible regarding any problem with your order.

Purchaser's Name (Please Print)

Purchaser's Signature

Title

PURCHASE ORDERS

Be sure to include all the necessary information with your order: Date, Shipping Address, Billing Address, Quantity of Items Desired, Authorized Signature, Desired Arrival Date (We will do our best to meet most desired shipping dates. However due to the fluctuation in shipping methods, times, and stocked items, we cannot guarantee the desired shipping dates that you list. Please call Customer Service for shipping times on specific items.)

FAX US 800-533-4793

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