ORDER AND INFORMATION REQUEST FORM

AVAILABLE COLORS

Scrub Shirts

Select Quantity Select Size: Price: Total Price:
$11.99
Scrub Pants Select Quantity
$11.99
V-Tunics Select Quantity Select Size:
$15.99
Elastic pant & V-tunic Top Select Quantity Select Size:
$19.99
Credit Card No: Expirey Date Select your payment method:
Total:
E-mail Address
Special Request/Catalog: Select:
Telephone Number

Facsimile Number

Name:
Delivery Address: Street:
City:
State:
Zip:

Standard Shipping and handling Charges

Total:

$1.00- $25.00

$25.01- $50.00

$50.01- $75.00

$75.01- $100.00

$100.01- $150.00

Ground:

$4.50

$5.50

$6.50

$7.50

$8.50

Mail to:

Fax :

Uniform World

2900 West sample Rd.

3509 Acapulco #343

Pompano Beach, Fl 33067

Order/fax by calling 1-954-975-5814

EST Wed-Sun 9:30 - 5



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