Mail Orders To: Standris Medical Supply, Inc. 149 Beech Street Coatesville, PA 19320 1-800-297-4721			Fax: 610-384-1012 Email Address: sales@standris.com
First Name _______________________________  Last Name ________________________________ Billing Address _____________________________________  Phone (______)___________________ City ______________________ State _____  Zip __________       Email _______________________
Product Name __________________ __________________ __________________ __________________ __________________ __________________ __________________	Item # ________ ________ ________ ________ ________ ________ ________	Color ________ ________ ________ ________ ________ ________ ________	Qty ________ ________ ________ ________ ________ ________ ________	Price Each $___________ $___________ $___________ $___________ $___________ $___________ $___________	Total $___________ $___________ $___________ $___________ $___________ $___________ $___________
		Total Items	________	Total Price	$___________
Pennsylvania Residents add 6% Sales Tax					$___________
Sub-Total					$___________
Shipping and Handling (see chart)					$___________
Total Due					$___________
Shipping and Handling Chart		METHOD OF PAYMENT (Check One Box). No COD’s. __ Check or Money Order enclosed (payable to Standris) __ VISA __ Master Card __ American Express __ Discover CARD NUMBER: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ EXPIRATION DATE: Month __ __ Year __ __ ________________________________________________ Signature Date

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Send questions and comments to: webmaster@standris.com.
Standris Medical Supply, Inc., 149 Beech St., Coatesville, PA 19320
Toll Free: 800-297-4721, Fax: 610-384-1012