PBS Med - Easy Order Form Customer No. __________________ Bill to Name __________________ Address __________________ Address2 __________________ Suite No. __________________ City __________________ State ________ *Zip: ________ Telephone __________________ Fax Number __________________ Buyers (first name) __________________ Toll Free 1-800-727-8885 Fax 1-800-525-4568 Email: Info@pbsmed.com Internet: www.pbsmed.com   Ship To Name (if different then Bill to) __________________ Address __________________ Address 2 __________________ City __________________ State ________ *Zip: ________ Qty Unit Catalog No. Description/Optional Unit Price Total ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ Sales Tax 6% (CT Only) _________ Total $ _________ Bill Me (Freight Added) Payment enclosed (Prepaid orders are shipped freight-free in the continental USA. For AK, HI, PR, and Pacific Is. Destinations, full freight charges will be added to invoice) Credit Card (see below) Freight Added Visa MasterCard American Express Account Number on Credit Card __________________ Expiration Date __________________ Signature __________________________