Page 17 - Hensler Surgicasl Aqualine SID - 2018
P. 17
BILL ONLY FORM
Order Fax:
910.399.7381
th
2420 South 17 Street STE G
Wilmington, NC 28401
(w) 910.399.7380
ATTN: Sean Hensler 910.599.4885 (Manager)
Julia Tew 910.409.5886 (Office Manager)
Customer/ Facility Name Account # Surgeon
Street Address City State Zip Phone Number
Purchase Order # Delivery Date Customer Name and Contact Customer Signature
Info
This P.O. will be used to bill Signature verifies that customer has
your account for the items taken ownership of and is
listed. purchasing the items below at the
prices listed.
Sales Rep/Distributor
Quant Catalog # Lot/Serial # Description Each Price Extended
Price
TBD
Prices Subject to Change TOTAL
