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Custom earpieces order form ph... Custom EarPieces Order Form Step 1: Patient Information Step 3: Customer Information Last Name: Ship To Acct Number: First Name: Address: Age: Gender: City: Third Party Patient Number: State: Zip:

Cookbook order formorder form... Cookbook Order Form:Order Form-Ver 2 8/17/07 11:23 AM Page 3 COOKBOOK A Guide to Healthy Eating for Adults with Disabilities Order Form Cookbook Order Form:Order Form-Ver 2 8/17/07 11:23 AM Page 4

Arbonne order form U.S. Client Order Form ordered by Ordering is easy through your Arbonne Independent Consultant or online at arbonne. Please attach Arbonne Price List and add total here. lineLine 3 TOTAL Attached to this order please find Check all that apply q Preferred Client Registration Form Must be attached if order includes a Preferred Client Registration Fee q Arbonne Price List total Product TOTAL 6366R09 01 2012 ARBONNE INTERNATIONAL LLC ALL RIGHTS RESERVED. A signed and fully completed Product Return Form must accompany a product return. Shipping fees are non-refundable. Please allow four to six weeks for processing. Promotional products and gift items may not be available for replacement and may at Arbonne s discretion be exchanged for an item of equal value. The Money Back Guarantee applies only to Clients and Preferred Clients who order directly from an Arbonne Independent Consultant or directly from the Company. com* method of payment Arbonne Independent Consultant Information Name Arbonne ID Billing Address Credit Card Type Check one q MasterCard q Visa q Discover q American Express City State ZIP Ship to Address If different from Billing Credit Card No* Address City Daytime Phone Evening Phone Card Expiration Date / Phone Total amount applied to this card Email Cardholder s Name Cardholder s Signature Email Date If Client has an Arbonne ID. Existing Clients registering as a Preferred Client my retain the same Arbonne ID. Note UPS and FedEx do not deliver to PO Boxes. Page item product qty SRP TOTAL Money Back Guarantee Arbonne offers a 45-day Money Back Guarantee on all products for Clients who are not completely satisfied* Product orders may be cancelled without any penalty or obligation within three 3 business days from the date of purchase. See reverse side for more information* shipping handling Product Order Total SRP UPS Ground 0 99. 99 100 199. 99 200 299. 99 300 399. 99 400 499. 99 500 999. 99 UPS Flat Rates UPS 3rd Day Air 14. 95 9. 75 21. 95 12. 95 28. 95 14. 95 30. 95 16. 95 32. 95 22. 45 35. 95 29. 95 49. 95 UPS 2 Day UPS Next Day 19. 99 29. 99 UPS 2nd Day and Next Day Air This charge is per carton* Program details may be revised at a later date. Surcharge to Alaska Hawaii Puerto Rico and U*S* Territories Up to 249. 99 order 2. 00 250 order 5. 00 Line 1 TOTAL Line 2 Preferred Client 20 Discount PRODUCT SPECIALS price Shipping fee waived with supplied FedEx Account. 5 Handling fee on FedEx orders. FedEx Account Circle one 2nd Day Air Overnight Standard or Priority LINE 1 LINE 2 PREFERRED CLIENT 20 DISCOUNT Ask your Arbonne Independent Consultant about special promotions and PwPs. Preferred Client Registration Fee LINE 3 Product Specials PRICE TOTAL 125 SRP for 25 125 SRP of products for 25 with each 250 RV increment. List items below or attach price list and add total here. LINE 4 SUBTOTAL Line 1-2 3 LINE 5 LINE 6 taxable Subtotal Line 4 5 LINE 7 Sales Tax Line 6 x Tax LINE 8 Order Total Line 4 5 7 New Preferred Client Free Product with 150 SRP FREE Ultimate Value Pack UVP New Preferred Clients can select 325 worth of products for 200.

Standing order form basic bank... Standing Order Form Instructions to your bank or building society 1 Details of the account where payments will come from Account Name Account number Sort Code 2 Details of the account where payments

Mri order forms Phone: 713.425.8100 Fax Orders: 713.425.8182 Email Orders: scheduling houstonmri.com www.HoustonMRI.com q q q q q 2600 N. Gessner, Ste. 150, Houston, TX 77080 5630 E. Sam Houston Pkwy N., Houston,

Thirty one order form Thirty-One ORDER FORM please press firmly and print legibly Guest Name Hostess Name Street Address Are you interested in City State Zip Phone s E-mail Party Date // Order item qty product description fabric/print Cash Consultant contact information font color font style Check Hosting a party yes maybe I d like to learn more Becoming a Consultant Having a catalog party Thirty-One product news Sharing the name of someone who would love Thirty-One personalization information cost enter the name or initials exactly as it should appear Credit Card Name on card Card Exp. / 3 digit code total price Product Subtotal 8 Shipping/Handling 4. 00 for orders NOT shipped to the Hostess Subtotal Billing Address Sales Tax Billing City/Zip Code Grand Total Signature For reorders parties or information about embroidery only You the Buyer may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction* See the Notice of Cancellation form on the reverse side for an explanation of this right. It is the Consultant s responsibility to safeguard all credit card information maintain a secure internet connection on PC using Party Plan ordering and to safely destroy ALL documents containing customer credit card information after the order is completed* white Consultant copy yellow Guest copy 1 pink Guest copy 2. 00 for orders NOT shipped to the Hostess Subtotal Billing Address Sales Tax Billing City/Zip Code Grand Total Signature For reorders parties or information about embroidery only You the Buyer may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction* See the Notice of Cancellation form on the reverse side for an explanation of this right. It is the Consultant s responsibility to safeguard all credit card information maintain a secure internet connection on PC using Party Plan ordering and to safely destroy ALL documents containing customer credit card information after the order is completed* white Consultant copy yellow Guest copy 1 pink Guest copy 2.

Cologuard order form COLOGUARD ORDER REQUISITION FORM EXACT SCIENCES LABORATORIES LLC 145 E. Badger Rd Ste 100 Madison WI 53713 P 844. 870. 8879 www. exactlabs. com Fax completed form to 844. 870. 8875 REQUIRED Provider Information PROVIDER INFORMATION Healthcare Organization Location Address Provider Name City State Zip NPI Phone Number or DEA if NPI is not available Fax Number To receive results for this order please provide a secure FAX number PATIENT INFORMATION Patient ID/MRN First Name Last Name DOB mm/dd/yyyy Sex Male Female Optional Patient label here or attach patient demographic sheet to order We will need to reach your patient to verify order details. Phone number is required. Email follow-up is not always available depending on the information needed from the patient. Initial Follow-up Type Phone Email Home Mobile Work Email Address optional TEST INFORMATION Test Name Cologuard Test Description Stool-based DNA test with hemoglobin immunoassay component Primary ICD-9 Code V76. 870. 8879 www. exactlabs. com Fax completed form to 844. 870. 8875 REQUIRED Provider Information PROVIDER INFORMATION Healthcare Organization Location Address Provider Name City State Zip NPI Phone Number or DEA if NPI is not available Fax Number To receive results for this order please provide a secure FAX number PATIENT INFORMATION Patient ID/MRN First Name Last Name DOB mm/dd/yyyy Sex Male Female Optional Patient label here or attach patient demographic sheet to order We will need to reach your patient to verify order details. Phone number is required* Email follow-up is not always available depending on the information needed from the patient. Initial Follow-up Type Phone Email Home Mobile Work Email Address optional TEST INFORMATION Test Name Cologuard Test Description Stool-based DNA test with hemoglobin immunoassay component Primary ICD-9 Code V76. 51 Special Screening for malignant select one neoplasm intestine colon Secondary ICD-9 Code optional Certi cation By ordering Cologuard I certify that I am a licensed medical professional authorized to order Cologuard. I acknowledge that the test is medically necessary and that the patient is eligible to use Cologuard. I accept responsibility for maintaining the privacy of test results and related information as required by HIPAA. I authorize Exact Sciences Laboratories Other to obtain reimbursement for Cologuard and to directly contact and collect a second sample from the patient if reportable results are not obtained from the initial sample. The above ICD-9 code is listed as a convenience. Ordering practitioners should report the diagnosis code s that best describes the reason for performing the test regardless of whether the code is listed above or not. Ordering Provider Signature Date of Order REQUIRED Patient Information PATIENT ADDRESS Shipping Address Billing Address Same as Shipping PATIENT INSURANCE/BILLING INFORMATION Policyholder Name Self Spouse Other Please enclose copy of the front/back of insurance card a patient demographic sheet or complete the information below.

Turpin spartans book store spi... Turpin Spartans Book Store Spirit Wear Order Form 2012 **Prices apply to sizes XS-XL. For each size larger than XL add $2.00 per size Name: Allow 2 weeks for Delivery Address: Make Checks Payable

Starbucks order form 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22 non fat / skim chai awake (black tea) milk vanilla cream frappucino chai cr me frappucino.

East bay paratransit ticket bo... East Bay Paratransit Ticket Book Order Form Complete this order form and mail to: East Bay Paratransit 1722 Broadway Oakland, CA 94612 Questions? Call (510) 287-5000. Mailing Information Send tickets

Form 385 dealers sales report... Reset FormPrint Form MOTOR VEHICLE BUREAU DEALERS REPORT DESK time, paper, and P OSave BOX 43, JEFFERSON CITY MO postage 651050043 utilizing (573) 5263669 WWW.DOR.MO.GOV/MVDL our online dealer sales

Tn annual sales report form ATTENTION DEALERS IMPORTANT!!! STATE OF TENNESSEE DEPARTMENT OF COMMERCE AND INSURANCE MOTOR VEHICLE COMMISION 500 JAMES ROBERTSON PARKWAY, 5th FLOOR NASHVILLE, TENNESSEE 372431153 TELEPHONE: 6157412711

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