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

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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. - RxPad Customer Service
830-3 Seton Court ~ Wheeling IL 60090

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Note: We screen diligently for fraudulent orders

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VERY IMPORTANT New Jersey State Law requires that all Rx Paper Orders are shipped to the address on file with the State of New Jersey. After submitting your order ..... the Micro Format Compliance Department requires that you send a copy of your State License to our customer service department by FAX FAX Number (847)520-0197 Orders will be processed ONLY after we have received a copy of your State License by Fax. IT'S THE LAW. Failure to send your License will delay the production of your order. NOTICE WITHOUT EXCEPTION, Your order WILL NOT BE PROCESSED until your License has been received. Not only is it the law; It is for your protection. We appreciate your co-operation with this requirement.

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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:

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Daytime Phone (include area code):

Evening Phone (include area code):

Fax (include area code):

e-mail address:

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DEA #

License # (required):
Expiration Date:

NPI # (required):
Doctor�s Signature ___________________________________________

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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.

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SHIP TO ADDRESS (if different than above)

Practice Name:

Physician Name:

Specialty (required):

Street Address(No P.O.Boxes):

City:

State: Zip:

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�Indicate Format Needed ~ Place "X" in box
PC41-NJ Format 1 (MD, DO, DS, DMD, DPM, DVM) Imprint up to 4 Names or 2 Names plus Facility Name Each name must be imprinted with License # and NPI # click to enlarge	PC42-NJ Format 2 (Facility Format) 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) click to enlarge	PC43-NJ Format 3 (Optician Format) � Imprint maximum 4 Names or 3 Names plus Facility Name. Each name must be imprinted with License # and NPI # click to enlarge	PC44-NJ Format 4 (Nurse Practitioner) New Jersey law requires only ONE Nurse Practitioner's name per script with ONE Collaborative Physician's name. Both the Nurse Practitioner's name and information plus the Collaborative Physician's name and information must be pre-printed on script. click to enlarge	PC48-NJ Format 5 (Physician Assistant) New Jersey law requires only ONE Physician Assistant's name per script with ONE Collaborative Physician's name. Both the Physician Assistant's name and information plus the Collaborative Physician's name and information must be pre-printed on script. click to enlarge

Please place �X� next to the number of pads needed.

1 part pads (100 sheets per pad)

20 pads ~ $7.55 per pad plus shipping by UPS

40 pads ~ $5.75 per pad plus shipping by UPS

80 pads ~ $5.05 per pad plus shipping by UPS

160pads ~ $4.85 per pad plus shipping by UPS

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2 part pads (50 sets per pad) original and copy

20 pads ~ $10.75 per pad plus shipping by UPS

40 pads ~ $8.65 per pad plus shipping by UPS

80 pads ~ $7.65 per pad plus shipping by UPS

160pads ~ $7.45 per pad plus shipping by UPS

Effective 2009
ALL NEW JERSEY SCRIPTS MUST BE CONSECUTIVELY NUMBERED

Enter Starting Number Here (i.e. 101)

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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)?

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 2009 (immediately), New Jersey Law requires that all Rx Pads be consecutively numbered

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

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If you are ordering Format 4 (Nurse Practitioner) or Format 5 (Physician's Assistant)
Click to complete additional Script Imprinting Information.

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Comments

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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:

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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.

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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 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.

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If you are ordering Format4 (Nurse Practitioner) or Format 5 (Physician's Assistant)
New Jersey law requires only ONE name per script
with ONE Collaborative Physician's name.
Along with your information, the Collaborative Physician's name and information must be pre-printed on script.
Please enter Collaborative Physician's information below.

After completing the above information
please click to complete the credit card information.

copyright � 2006-2009 Micro Format, Inc. ~ Wheeling IL
All Rights Reserved