MEDASIAP'S ORDER FORM

550 Forest Street * Spartanburg, SC 29303 * 864-582-3018

SHIP TO:

NAME

E-MAIL ADDRESS

STREET ADDRESS (Must have street address, Not P.O. Box)

CITY / STATE / ZIP

DAYTIME PHONE

QTY ITEM # DESCRIPTION OF ITEM PAGE # PRICE TOTAL AMOUNT

SUB TOTAL:

SALES TAX (SC only) 5%:

POSTAGE & HANDLING: (see below)

TOTAL:

POSTAGE CHARGES

METHOD OF PAYMENT

CREDIT CARD #
(Enter your 16, 15, or 14 digit number)

CREDIT CARD NAME
(as it appears on card)
&
EXP. DATE

Orders totaling $25.00 - $49.99 Add $7.00

MASTER CARD

Orders totaling $50.00 - $74.99 Add $8.00

VISA

Orders totaling $75.00 - $99.99 Add $9.00

AMERICAN EXPRESS

Orders totaling $100.00 - Up Add $10.00

DISCOVER

Would you like to receive a catalog? Yes No

Are you interested in income opportunities? Yes No

This site designed by Marilyn Denise Hawes, Web Designer per Medasia's specifications.

Marilyn's Home Page | Marilyn's Portfolio | Contact Marilyn

Copyright © August 2005 Marilyn Denise Hawes

MEDASIAP'S ORDER FORM

550 Forest Street * Spartanburg, SC 29303 * 864-582-3018

SHIP TO:

NAME

E-MAIL ADDRESS

STREET ADDRESS (Must have street address, Not P.O. Box)

CITY / STATE / ZIP

DAYTIME PHONE

SUB TOTAL:

SALES TAX (SC only) 5%:

POSTAGE & HANDLING: (see below)

TOTAL:

POSTAGE CHARGES

METHOD OF PAYMENT

CREDIT CARD #
(Enter your 16, 15, or 14 digit number)

CREDIT CARD NAME
(as it appears on card)
&
EXP. DATE

Orders totaling $25.00 - $49.99 Add $7.00

MASTER CARD

Orders totaling $50.00 - $74.99 Add $8.00

VISA

Orders totaling $75.00 - $99.99 Add $9.00

AMERICAN EXPRESS

Orders totaling $100.00 - Up Add $10.00

DISCOVER

Would you like to receive a catalog? Yes No

Are you interested in income opportunities? Yes No

This site designed by Marilyn Denise Hawes, Web Designer per Medasia's specifications.

MEDASIAP'S ORDER FORM

550 Forest Street * Spartanburg, SC 29303 * 864-582-3018

SHIP TO:

NAME

E-MAIL ADDRESS

STREET ADDRESS (Must have street address, Not P.O. Box)

CITY / STATE / ZIP

DAYTIME PHONE

SUB TOTAL: SALES TAX (SC only) 5%: POSTAGE & HANDLING: (see below) TOTAL:

POSTAGE CHARGES

METHOD OF PAYMENT

CREDIT CARD # (Enter your 16, 15, or 14 digit number)

CREDIT CARD NAME (as it appears on card) & EXP. DATE

Orders totaling $25.00 - $49.99 Add $7.00

MASTER CARD

Orders totaling $50.00 - $74.99 Add $8.00

VISA

Orders totaling $75.00 - $99.99 Add $9.00

AMERICAN EXPRESS

Orders totaling $100.00 - Up Add $10.00

DISCOVER

Would you like to receive a catalog? Yes No

Are you interested in income opportunities? Yes No

This site designed by Marilyn Denise Hawes, Web Designer per Medasia's specifications.

SUB TOTAL:

SALES TAX (SC only) 5%:

POSTAGE & HANDLING: (see below)

TOTAL:

CREDIT CARD #
(Enter your 16, 15, or 14 digit number)

CREDIT CARD NAME
(as it appears on card)
&
EXP. DATE