ALATECH HEALTHCARE PRODUCTS
MMCAP CUSTOMER ORDER INFORMATION
Fill in the blanks and click the Submit Order button at the bottom

Purchase Order #     MMCAP Vendor#     Requested Ship Date
Terms: 30 Days Net (Unless agreed otherwise by phone).
Tax Exempt Number
SOLD TO
 
SHIPPING INFO
Organization   Same as Sold To
Address   Organization
    Attention
    Shipping Addr
Buyer's Name    
Buyer's Title    
Phone   Receiver's Phone
Fax    
     
REMIT PAYMENT TO
 
INVOICE INFO
  Alatech Healthcare Products   Organization
  Attn: Billing Department   Attention
  1600 State Docks Road   Address
  Eufaula, Alabama 36027    
       
Phone 1-877-390-9337 or   Phone
  1-334-678-5401   Fax
Fax 1-334-678-6732      

Item Number
Quantity
# of Cases
Description
Unit Price
Total
   
Shipping & handling charges apply at $12
per case on orders of less than 8 cases.
Subtotal

**Special Offer:
Free Shipping and Handling on orders of more
than 7 cases with the same Ship To address.

**Shipping
    Misc
    Balance Due


Special Instructions
 

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