Fax Order Form

POUCH POCKETS FAX ORDER/INVOICE Date: ______

(PMIMD Las Vegas Conference Price List good til 11/30/2011 only)

Pouch Pocket Wholesale Pricing	Box/6-wGEL	Box/12– w/GEL	Box/24– w/GEL
Ouch Pouch Pack Covers - 3oz 3 x 3 Square with Gel Pack for "cold therapy"	$24.00	$45.00	90.00

Pouch Pockets/Gel Pack "cold/heat therapy"	1Sample, w/Gel	with Gel	with Gel
Small Covers– 4x6 inch size □ boxes___	$6.00, $34.00	$68.00	$125.00
Medium Covers - 8x11 inch size □ boxes ___	$12.00, $65.00	$135.00	$265.00
Large Covers - 12x15 inch size □ boxes___	$18.00, $96.00	$200.00	$425.00
Cervical - 4x11 inch size □ boxes____	$8.00, $45.00	$90.00	$185.00

(Circle existing size or list custom dimension and list number of boxes requested, and leave shipping phone number so order questions can be addressed if necessary)

For payment by BUSINESS, PERSONAL CHECK or MONEYORDER:

Shipping Name _________________________________________________

Shipping Address_________________________________________________

_________________________________________________________________

Shipping Phone Number__________________________________________

Email Address _______________________________________

Credit Card to be processed on-line through PayPal, or Pay Credit Card Direct:

CARD NAME_____________________________________

Card ID# _________________________________________

Expiration Date ____________Auth# _________

(Shipment upon payment Verification of funds)

Subtotal: _____________

Tax: 9.5% _____________ (Arizona Residents Only)

Shipping : $5.50 (per order)

Balance Due : ___________

4632 W Tierra Buena Lane * Glendale, AZ 85306

1-800-261-3062 * 602-993-9284 * fax: 602-237-5159

email: appsservices@aol.com