Micro Format Inc

www.PrescriptionPaper.com ~ www.RxPaper.com

830-3 Seton Court ~ Wheeling IL 60090

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 ~ Wheeling IL 60090

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 packageplus shipping

___ 1,000 sheets �. $80.00 per packageplus shipping

___ 2,500 sheets (1 carton) $187.50 per cartonplus shipping

___ 5,000 sheets (2cartons) �. $175.00 per cartonplus shipping

___ 10,000 sheets (4 cartons)... $150.00 per cartonplus 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 packageplus shipping

___ 1,000 sheets �. $90.00 per packageplus shipping

___ 2,500 sheets (1 carton) $212.50 per cartonplus shipping

___ 5,000 sheets (2 cartons)�. $200.00 per cartonplus shipping

___ 10,000 sheets (4 cartons) ... $175.00 per cartonplus shipping

___ Rx 505 (Script Top Half of Sheet)

___ Rx 510 (Script Top Left-Hand Corner)

 

___ 500 sheets �.��� $70.00 per packageplus shipping

___ 1,000 sheets �. $90.00 per packageplus shipping

___ 2,500 sheets (1 carton) $212.50 per cartonplus shipping

___ 5,000 sheets (2cartons) �. $200.00 per cartonplus shipping

___ 10,000 sheets (4 cartons)... $175.00 per cartonplus shipping

 

State Approved Laser Prescription Paper ~ 5-1/2� x 8-1/2�~ perforated 4-1/4� from top (over under)

(circle format needed)

Florida:RXEC503-FL ~ Indiana: RXEC-503-IN ~ Kentucky: RXEC503-KY ~ West Virginia: RXEC503-WV

 

____�� 500 sheets �. $55.00 per packageplus shipping

____ 1,000 sheets �. $75.00 per packageplus shipping

____ 2,500 sheets (1 carton) $175.00 per cartonplus shipping

____ 5,000 sheets (2 cartons) $150.00 per cartonplus shipping

____ 10,000 sheets (4 cartons) � $110.00 per cartonplus 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 licensingagreement, 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 ~ Wheeling IL 60090

Area Code 847/520-4699~ Toll Free: 800-333-0549 ~ Fax: 847/520-0197

www.PrescriptionPaper.com ~ www.RxPaper.com ~ www.PrescriptionPads.net

 

copyright�� � 2004-2009Micro Format, Inc. ~ Wheeling IL

All Rights Reserved