Mail:  Luvmedical - PO Box 61048 - Lafayette, LA 70596  or  Fax: 888-262-0839
> > > > > > >
Date         PO Number        
(if applicable)
Company          
     
Full Name          
Title          
Telephone          
Billing Address Shipping Address  (Physical Location)
                           
                           
City           City              
State / Province     Zip Code     State / Province     Zip Code        
Item Number Description Size Color Qty Cost  Ext .Cost
                       
                   
                       
                   
                       
                       
                       
                       
                       
      ##############################################################################################
Circle Payment Method     Subtotal    
  1. BUSINESS OR PERSONAL CHECK     * Processing Fee (if any)    
  2. BANK MONEY ORDER     Promotional Discount Number (if any):  # # # #  # # # # #
  3. VISA,   MASTERCARD,   AMEX       Nos.:  # # # #  # # # # #
  Card Nos.:               Sales Tax (LA residents add 8.5%)    
  Expiration Date:     * * Shipping and Handling    
  Card Code (3 or 4 digit # on back of card):   Amount Due (USD$)       
Please submit your Fax Number, or an Email Address to receive your Order Confirmation.
               
* Minimal Order Requirement of $100.00. If subtotal is less than minimum requirement, please add an additional $10.00 to your order.
* * To calculate shipping & handling, multiply order subtotal by .15 and add $4.00 handling fee to that amount.
     If order will be shipped to a residential address, please add a $2.31 carrier surcharge to shipping amount as well.
Buyer Signature