Micro Format Inc -------------New Jersey Laser Rx Paper Fax Order Form
www.PrescriptionPaper.com ~ www.PrescriptionPads.net
830-3 Seton Court ~ Wheeling IL 60090
Toll Free Order Line: 800-333-0549 Fax: 847-520-0197 ~ Local Tel:847-520-4699

New Jersey Laser Prescription Paper FAX ORDER form

Micro Format, Inc. along with our Manufacturing Partner Printco
is an approved NJ Pharmacy Board Security Prescription Paper Printer

After completing all of the information,
please print a copy of this ORDER FORM and send it by FAX to (847)520-0197

You may also send your order by mail to:
Micro Format, Inc. - RxPaper Customer Service
830-3 Seton Court ~ Wheeling IL 60090

Note: We screen diligently for fraudulent orders

VERY IMPORTANT ~~~
The New Jersey State Pharmacy Board requires that a copy of this order
be sent to us by FAX. Please FAX this signed Order Form to
MICRO FORMAT CUSTOMER SERVICE
Fax Number: (847)520-0197
Thank you.

Person Entering Order

Order Date:

Is this your first order? (Yes or No)

If this is a Re-Order ...
Please enter BATCH NUMBER as it appears on your scripts

Purchase Order Number (optional):

Practice Name:

Physician Name:

Specialty (required):

Street Address(No P.O.Boxes):

City:

State: Zip:

Daytime Phone (include area code):

Evening Phone (include area code):

Fax (include area code):

e-mail address:

DEA #

License # (required):
Expiration Date:

NPI # (required):
Doctor’s Signature:
___________________________________________

NEW JERSEY LAW REQUIRES:

The License Number and NPI# to be printed for each doctor listed.

Only ONE LOCATION may appear on the front of the script.
We have been notified by the State of New Jersey ....
All doctor's names MUST be printed on the front of the script.
The font "point size" can be no smaller than 7pt.
Thus the imprint format we must use contains:
The Practice Name, up to THREE (3)doctors names,
license number, NPI number and (optional) DEA Number,
address and telephone number.
Printing additional locations on the back of the script is available
at an additional charge of $25.00 per 1000.
This charge will be added to the total price of your order.

Additional names MAY NOT be printed on the back of the script.

Effective 2008 (immediately),
New Jersey Law requires that all Rx Scripts be consecutively numbered
VERY IMPORTANT SHIPPING INFORMATION .....
New Jersey Law requires us to ship your order to the address on file with the State of New Jersey. This is your address as shown in the State of New Jersey data base. If the address on file with the state does not agree with the "Ship To" address, we cannot process your order.
After submitting order, a copy of your New Jersey License MUST be sent to us by FAX Fax Number (847)520-0197
When your order is delivered by UPS, a signature will be required. If the address on file with the state does not agree with the "Ship To" address, we cannot process your order.
When your order is delivered by UPS, a signature will be required.

SHIP TO ADDRESS (if different than above)

Practice Name:

Physician Name:

Specialty (required):

Street Address(No P.O.Boxes):

City:

State: Zip:

New Jersey Laser Prescription Forms
Format #1 (MD,DO,DS,DMD,DPM,DVM)
Imprint up to 3 Names
or 2 Names plus Facility Name
Each name must be imprinted with License # and NPI #

Check Box
to ORDER Format
Item#NJMD1

ENLARGE VIEW

Item# NJMD1
8-1/2" x 11"
One Script-Top Left

2,500 sheets
$432.50 plus shipping by UPS

5,000 sheets
$650.00 plus shipping by UPS

10,000 sheets
$1,070.00 plus shipping by UPS

New Jersey Laser Prescription Forms
Format #2 (MEDICAL FACILITY)

Imprint the Facility Name, Address and Phone Number.
Only ONE LOCATION may appear on the front of the script.
One Doctor's Name, NPI# and License Number must appear on script.
Additional locations may be printed on back of the script
(at an additional charge)

Check Box
to ORDER Format
Item#NJHC1

ENLARGE VIEW

Item# NJHC1
8-1/2" x 11"
One Script-Top Left

2,500 sheets
$432.50 plus shipping by UPS

5,000 sheets
$650.00 plus shipping by UPS

10,000 sheets
$1,070.00 plus shipping by UPS

New Jersey Laser Prescription Forms
Format #3 (OPTICIAN)
Imprint maximum 4 Names or 3 Names plus Facility Name.
Each name must be imprinted with License # and NPI #

Check Box
to ORDER Format
Item#NJOP1

ENLARGE VIEW

Item# NJOP1
8-1/2" x 11"
One Script-Top Left

2,500 sheets
$432.50 plus shipping by UPS

5,000 sheets
$650.00 plus shipping by UPS

10,000 sheets
$1,070.00 plus shipping by UPS

IMPRINTING INFORMATION for upper portion of Prescription Paper

Please fill-in the information that needs to be imprinted on the top of each sheet.
Un-imprinted forms are not available.

It is VERY IMPORTANT that you fill-in the information below carefully.
This is the information we will use to imprint your scripts.
You are responsible to make sure that all numbers that are to be printed on
your scripts (DEA# NPI# and License #) are entered correctly.
All information will be printed exactly as specified below

New Jersey Law requires that your License# and NPI# must be printed on your scripts.

Do you want your DEA# to be printed on your scripts? (Yes or No)

Multiple names can be printed on prescription forms.
We can print a maximum of THREE (3) names.
The License Number must be printed next to each name.

Suggested Printing Format:

Practice Name
Doctor's Name
Address
City, ST, Zip Code
Tel: XXX-XXX-XXXX Fax: XXX-XXX-XXXX

Lic. XXXXXXX NPI# XXXXXX DEA# XXXXXXXX

Enter Prescription Paper Imprinting Information HERE

Printing additional names and/or locations on the back of the script is
available at an additional charge of $25.00 per 1000.
This charge will be added to the total price of your order.
For additional information please CALL Customer Service at (800)333-0549.

Comments

CREDIT CARD INFORMATION
We accept Visa, MasterCard and American Express

Type Credit Card (Visa, MasterCard, Amex)

Credit Card Number

Exp. Date (MM/YY):

CCV Number ( found on the back of the card )

Bank Name on Card:

Card Holder's Name:

Credit Card Billing Address:
Zip Code:

After completing this FAX ORDER FORM .....
Please print this order form and send it by Fax to Micro Format Customer Service.
Our Fax Number is (847)520-0197
Thank You.

Under our licensing agreement, all order for Document Security Paper and Prescription Paper 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 12 to 15 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

New Jersey Laser Prescription Forms Format #1 (MD,DO,DS,DMD,DPM,DVM) Imprint up to 3 Names or 2 Names plus Facility Name Each name must be imprinted with License # and NPI #

Check Box to ORDER Format Item#NJMD1 ENLARGE VIEW Item# NJMD1 8-1/2" x 11" One Script-Top Left 2,500 sheets $432.50 plus shipping by UPS 5,000 sheets $650.00 plus shipping by UPS 10,000 sheets $1,070.00 plus shipping by UPS


New Jersey Laser Prescription Forms Format #2 (MEDICAL FACILITY) Imprint the Facility Name, Address and Phone Number. Only ONE LOCATION may appear on the front of the script. One Doctor's Name, NPI# and License Number must appear on script. Additional locations may be printed on back of the script (at an additional charge)
Check Box to ORDER Format Item#NJHC1 ENLARGE VIEW Item# NJHC1 8-1/2" x 11" One Script-Top Left 2,500 sheets $432.50 plus shipping by UPS 5,000 sheets $650.00 plus shipping by UPS 10,000 sheets $1,070.00 plus shipping by UPS


New Jersey Laser Prescription Forms Format #3 (OPTICIAN) Imprint maximum 4 Names or 3 Names plus Facility Name. Each name must be imprinted with License # and NPI #
Check Box to ORDER Format Item#NJOP1 ENLARGE VIEW Item# NJOP1 8-1/2" x 11" One Script-Top Left 2,500 sheets $432.50 plus shipping by UPS 5,000 sheets $650.00 plus shipping by UPS 10,000 sheets $1,070.00 plus shipping by UPS