Medsbag fax order form

Prepare for Evacuation Now! - with MedsBag (Patent #0564217)
Keep Important Medical Records & Meds together!

ALL SALES ARE FINAL. NO REFUNDS unless product damaged during shipment & notification within 24 hrs of being received.
Shipment is by UPS ground unless other special arrangements are made prior to shipping.
Shipping charges are added to invoice and must be paid prior to shipment.
Orders shipped after payment received. Allow 3-4 weeks for shipping.

Company Name:	____________________________________________________
Buyers Name:	_____________________________		Title: _____________________
Street Address:	____________________________________________________
City:	____________________________	State:		______	Zip:	________
Phone:	_____________________ Fax: ____________________
Email:	___________________________________________

Shipping address is the same: _____ or, Shipping address different, please ship to:

Company Name:	____________________________________________________
Contact Name:	______________________________		Title: ____________________
Street Address:	_______________________________
City:	______________________________	State:		____	Zip:	____________
Phone:	____________________ Fax: ___________________
Email:	___________________________________

Please check one of the following that applies to this order:

Order Quantity:

x $12.95 each = Total (before shipping):

Credit Card: Visa or MasterCard

Name on Card: _________________________ Expiration Date: __________
Card Number: _______________________________________
Card Billing Address: _____________________________________________

Check: (payable to Senior Quest, address below - order shipped after check is processed.)

Please let us know how you found out about MedsBag: _________________________

Thank you.