Ordering Form
Customer Account#
Date: ____/____/____
___________________________
Representative taking order
Customer Name:
Specialty:
Bill To:________________________________________________
Customer P.O. #:_______________________________________
______________________________________________________
______________________________________________________
Method of Shipment: _____FedEx
Phone #: (
)______________________________________
_____Next Day by 8:30am
_____Next Day by 10:30am
_____Next Day - Afternoon
_____Two Day
_____Ground
_____Other_____________
Ship To:______________________________________________
______________________________________________________
______________________________________________________
Phone #: (
_____UPS
)______________________________________
Would you like to receive information via email about
BIOMET 3i’s Products, Services and Events?
n Yes n No
Method of Payment:
n Credit Card: _____Visa _____MasterCard _____AMEX
Card #:____________________________________________
Expiration Date:_____________________________________
Email Address: __________________________________
Special Instructions:
n C.O.D.
Contact Name:
Product No.
Date:
n Bill - Net 30
Quantity
Order Number:
BIOMET 3i
4555 Riverside Drive
Palm Beach Gardens, FL 33410
Phone: 800-342-5454 • Fax: 561-776-1272
Website: www.biomet3i.com
Description
Order Total:
Thank you for your patronage!
42
Discount
Unit Price
Customer Service Representative:
Total