| Click on your printer icon to print
this page and mail or fax it
to us along with payment to 'MediSpell'.
10824 Sheldon Road Tampa, FL 33626
Fax: 813-902-6270
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Date:
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Telephone:
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(______) ________________________________ EXT ____________
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Name:
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________________________________________________________ |
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Company:
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________________________________________________________ |
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Email:
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________________________________________________________ |
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Address:
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City:
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State:
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______ Zip Code: ___________
Country:________________
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Method of Payment:
P.O. Number:_________________ (Requires prior approval and copy of
purchase order) Check____ Visa____
MasterCard____ American Express____ Discover____
Credit Card Number:__________________________________ Exp. Date: ______/______
Name on Card:_____________________________________
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Quantity
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Description |
Unit Price |
Total |
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MediSpell - 1 User License |
$19.95 |
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MediSpell - 5 User License |
$95.00 |
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MediSpell - 10 User License |
$180.00 |
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MediSpell - 25 User License |
$395.00 |
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MediSpell - 50 User License |
$695.00 |
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MediSpell - 75 User License |
$930.00 |
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MediSpell - 100 User License |
$1110.00 |
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*Add Shipping Cost |
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UPS Ground |
$8.50 |
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2nd Day Air |
$17.50 |
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Airborne Overnight |
$29.50 |
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International Shipping |
$25.00 |
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Subtotal: |
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Tax (7%):
(FL
Residents Only) |
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| *Shipping: |
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| Grand Total: |
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