Order Form V.E. RALPH P.O. Box 633 · 320 Schuyler Ave. Kearny, New Jersey 07032-0633 SOLD TO: www.veralph.com · Call 1-800-526-1196 · Fax 1-800-772-7203 Regular Business Hours are 8:30 AM to 5:00 PM Mon­Fri. After business hours, our Voice-Mail System is available 24 hours a day for orders, messages or inquiries. SHIP TO: Name ________________________________________________ Address ______________________________________________ State ______________________________ Zip________________ Date __________________________________________________ Daytime Phone ____________ E-Mail Address ________________ Quantity Unit Price Total Price City __________________________________________________ CONTACT V.E. RALPH TODAY FOR FAST SERVICE The Emergency Care Products Specialists Name ______________________________________________ Address ____________________________________________ City ________________________________________________ State Purchase Order No. __________________________________ Catalog No. Description Ordered By __________________________________________ ____________________________ Zip ______________ All Orders shipped within New Jersey, Pennsylvania and New York are subject to a sales tax unless otherwise evidenced by a tax exempt number and certificate. Tax Exempt Number___________________________ Certificate enclosed______ SHIPPING: Continental United States orders are shipped prepaid via UPS (United Parcel Service) unless size or weight limitations dictate otherwise. (UNDER $150.00 include $10.00 for SHIPPING) Name as appears on card: _______________________________________Signature ______________________________________ METHOD OF PAYMENT (Check One) Account Number________________________________ Expiration Date________ Card ID Number___________________________ Money Order (No Personal Checks) Net 30 Days on Approved Credit V.E. Ralph welcomes VISA, MasterCard, American Express and Discover payment. Please complete the following to ensure proper invoicing and shipping. TOTAL Ë MasterCard / VISA / American Express / Discover Ë Pricing and product availability subject to change without notice. Ë V.E. RALPH 1-800-526-1196 · www.veralph.com 97
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