Micro Format Inc
www.PrescriptionPaper.com
~ www.RxPaper.com
830-3 Seton Court ~
Toll Free Order Line: 800-333-0549
Fax:847-520-0197 ~ Local Tel:847-520-4699
Secure Laser Prescription Paper
Please print a copy
of this Order Form and use it as a work sheet.
After completing all
of the information, send your order by FAX to (847)520-0197
You may also send your
order by mail to:
Micro Format, Inc � Laser RxPaper Customer Service
830-3 Seton Court ~
Note: We screen diligently for fraudulent orders.
At Micro Format, printing Security Prescription Paper is our
business ... not a side line !�
Order Date: __________________________
Purchase Order Number (optional): __________________________
Practice Name:
_______________________________________________________________________________
Physician Name:
_____________________________________________________________________________
Specialty:
____________________________________________________________________________________
Street Address
(No P.O. Boxes Please):
____________________________________________________________
Address: _____________________________________________________________________________________
City:
_______________________________________State:
_________________ Zip:
______________________
Is this order shipping to a residence
?� ____Yes��
____ No����
(If yes, a signature will be
required when package is delivered)
Daytime Phone
(include Area Code):
_______________________________________________________________
Evening Phone
(include Area Code):
_______________________________________________________________
e-mail: ____________________________________________ Fax Number:
________________________________
DEA #
_______________________ License #
________________________ Expiration Date:
_________________
SHIP TO ADDRESS� (if different than above)
Practice Name:
__________________________________________________________________________________
Physician Name:
________________________________________________________________________________
Street Address
(No P.O. Boxes Please): ______________________________________________________________
Address:
_______________________________________________________________________________________
City:
_________________________________________State:
_______________ Zip:
________________________
Indicate Laser Script
Format and Quantity Required
___ Rx 503 (Full
Sheet)
___ 500 sheets �.��� $� 60.00 per package� plus shipping
___ 1,000 sheets �. $� 80.00 per package� plus shipping
___ 2,500 sheets (1 carton) �� $187.50 per carton� plus shipping
___ 5,000 sheets (2� cartons) �. $175.00 per carton� plus shipping
___ 10,000 sheets (4 cartons)� ... $150.00 per carton� plus shipping
___ Rx503-P2 Perforated in half
___ Rx503-P3 Perforated in thirds
___ Rx503-P4 Perforated in quarters
___ Rx503-P5 Special
Perforations � Landscape Script Top Left
___ Rx503-P6 Special
Perforations � Landscape Script Bottom Left
___ Rx503-C2 Cut in
half (8-1/2� x 5-1/2�)
___ Rx503-C4 Cut in quarters (4-1/4� x 5-1/2�)
___ 500 sheets �.��� $� 70.00 per package� plus shipping
___ 1,000 sheets �. $� 90.00 per package� plus shipping
___ 2,500 sheets (1 carton) �� $212.50 per carton� plus shipping
___ 5,000 sheets (2 cartons)�. $200.00 per carton� plus shipping
___ 10,000 sheets (4 cartons) ... $175.00 per carton� plus shipping
___ Rx 505 (Script
Top Half of Sheet)
___ Rx 510 (Script
Top Left-Hand Corner)
___ 500 sheets �.��� $� 70.00 per package� plus shipping
___ 1,000 sheets �. $� 90.00 per package� plus shipping
___ 2,500 sheets (1 carton) �� $212.50 per carton� plus shipping
___ 5,000 sheets (2� cartons) �. $200.00 per carton� plus shipping
___ 10,000 sheets (4 cartons)� ... $175.00 per carton� plus shipping
State Approved Laser Prescription Paper ~ 5-1/2� x 8-1/2��
~ perforated 4-1/4� from top (over under)
(circle
format needed)
____�� 500 sheets �. $� 55.00 per package� plus shipping
____ 1,000 sheets �. $� 75.00 per package� plus shipping
____ 2,500 sheets (1 carton) �� $175.00 per carton� plus shipping
____ 5,000 sheets (2 cartons) �� $150.00 per carton� plus shipping
____ 10,000 sheets (4 cartons) � $110.00 per carton� plus shipping
CREDIT CARD INFORMATION
We accept Visa, MasterCard and American Express
Type Credit Card (Visa, MasterCard, Amex) _______________________________
Credit Card Number ___________________________________________________________________________
Exp. Date (MM/YY): ______________________________
3 number code (on the back of the card) _________________
Bank Name on Card: ___________________________________________________________________________
Card Holder�s Name: ___________________________________________________________________________
Credit Card Billing Address: ______________________________________________Zip Code: ______________
Under our licensing� agreement, all order for Document
Security Paper and Prescription Pads are reviewed and the information is
confirmed by our Document Security Compliance Team.� The use of Script Paper is controlled by
Federal and State Agencies.� Any attempt to purchase script paper by
unauthorized persons or by persons providing falsified information will be reported to the proper authorities
for prosecution to the full extent of the law.
Acceptance of any and all orders for document security and prescription paper will be determined by the Micro Format Document Security Compliance Team.
Orders ship within 2 to 3 business days from the time they are received by our order entry department.
Please allow extra time for shipping by UPS.
Thank you for your order.
Micro Format, Inc. ~ 830-3 Seton Court ~
Area Code 847/520-4699� ~ Toll Free: 800-333-0549 ~ Fax: 847/520-0197
www.PrescriptionPaper.com ~ www.RxPaper.com ~ www.PrescriptionPads.net
copyright�� � 2004-2009�
Micro Format, Inc. ~
All Rights Reserved