Name:
Company/Dept:
City/State/Zip:
Tel:
_______________________________________________________________________________________________
Please send me the following items: enter quantity of cases desired by size:
$45.00 / case
Latex - lightly powdered
XS
S
M
L
XL
$55.00 / case
Latex - powder free
XS
S
M
L
XL
$45.00 / case
Vinyl - lightly powdered
XS
S
M
L
XL
$55.00 / case
Vinyl - powder free
XS
S
M
L
XL
$75.00 / case
Nitrile - powder free
XS
S
M
L
XL
$75.00 / case
Nitrile - protein free
XS
S
M
L
XL
All above: 100 gloves/box, 10 box/case
Total Cases:
Free delivery via Federal
Express (3 or more cases)
_______________________________________________________________________________________________
Payment Information:
Bill Me
Charge to my Credit Card
Visa
Master Card
Card Number:
American Express
Exp:
Discover
Security Code:
MEDICAL DIMENSION GROUP, INC
1-847-426-9772
_____________________________________________________________________________________________
Order Form/Exam Gloves
Order by fax: 1-847-426-5961 Email: mdgrp@comcast.net Order by phone: 1-847-4269772