Endoscopy Development Company LLC
www.edcparts.com		   Fax Order
Print Date: 3/9/2010
Bill To:
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Company:

Address


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Ph:

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Ship To:
Contact:

Company:

Address


City/State/Zip

Ph:

Fax:
FedEx
P.O. Number Req. Date Ship Via Payment (select one)
      Credit Card / C.O.D.

Quantity EDCItem Description Unit Price Amount
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
Subtotal $
Shipping & Handling  
Total $


Payment Information
Please include the following information:

Name_______________________________________________________

Street Address________________________________________________

____________________________________________________________

City/State/Zip_________________________________________________

Daytime Phone (Required) _______________________________________

Credit Card # VISA MC AMEX DISC ________________________________

Card Verfification Code** ______________

Expiration Date ________________________

Signature _____________________________________

Shipping method: (Please select 1)
Express Saver ($ 14.00)
Priority Overnight(P1) ($ 22.00)
Standard Overnight ($ 18.00)

**Where to locate your Card Verification Code


Payment must be made via credit card or COD only, $0.00 minimum before freight. Orders received after 2 PM CST will be processed on the next business day.



When completed please fax/mail to:
Endoscopy Development Company LLC
3407 Hollenberg Drive

Bridgeton
Missouri
63044
Ph: 888.343.4441 (Toll Free) or 314.344.4441
Fax: 314.344.4444