ORDER FORM

	Bill To: (Please print clearly)	Ship To: (only if different than Bill To)
Name/Title
Organization
Address 1
Address 2
City/St/Zip
Phone
Fax
E-mail

SKU #	Description	Unit	Qty	Price







Comments or special instructions			Subtotal
			S&H
			*Tax
			Total
Sales Tax must be added to all customers in Texas (8.25%) unless tax exempt form on file. All international orders must be prepaid. Call or email for charges. Mail completed order form along with payment to: Healthcare Services by A.C.T.N.T., LLC* * P.O. Box 1181 * Mineral Wells, TX 76068 If paying by credit card you can fax completed order form to 866-822-2868 or 940-325-0590

Method of Payment		Shipping Table
o Check (made payable to Healthcare Services by A.C.T.N.T., LLC)	0.01-99.99		$8.50
o o Card #	100.00-199.99		$10.50
Exp Date: Signature:	200.00-299.99		$12.50
Print Name:	>300.00		$14.50
o Purchase Order No. __________________ must include hard copy with order form.