Medco Sports Medicine Printable Order Form
(This form is for customers to print out, and order by mail or by fax. It is not for on-line orders)
Medco Sports Medcine 500 FILLMORE AVE. TONAWANDA, NY 14150 USA Fax: 1-800-222-1934 Phone: 1-800-556-3326 (24 Hours/Day, 7 Days/Week)
	SHIP TO:		Phone No.:	_______________________________
Co. Name:	_______________________________		Purchase Order No.:	_______________________________
Attn:	_______________________________		Authorized By:	_______________________________
Address:	_______________________________		Title or Dept.:	_______________________________
City:	_______________________________		Date:	_______________________________
State:	______________ Zip:___________		Customer No:	______________ Zip:___________
	BILL TO: (If different from SHIP TO)		Bill Our Account
Co. Name:	_______________________________		Charge My Credit Card
Attn:	_______________________________		Credit Card No.:	_______ _______ _______ _______
Address:	_______________________________		Expiration Date:	___/___
City:	_______________________________		Signature:	_______________________________
State:	______________ Zip:___________		Name of Cardholder:	_______________________________
Circle One Type: Visa MasterCardAmerican ExpressDiscoverSmartPayTM

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Shipping & Handling
(AL,AR,AZ,CA,CO,CT,DE,DC,FL,GA,IL,IA,IN,KS,KY,LA,MA,MD,MI,MN,MS,MO,NE,NM,NJ,NY,NC, ND,NV,OK,OH,OR,PA,RI,SC,SD,TN,TX,UT,VA,WA,WV,WI Customers Only)Sales Tax
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