Daltonmedical

Dalton Medical Authorized Dealer Order Form

Online Order

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DALTON MEDICAL CORPORATION

4235 McEwen Road, Farmers Branch, Texas 75244

TEL: 469-329-5200 FAX: (972) 386-6615

Date (MM/DD/YY):

/ /

New Customer OR

Order Person:

Existing Comp#:

Bill To:

PO #:

Address:

City:

State:

Zip:

Phone Number:

Fax Number:

If different from above --

Ship To:
Shipping Address:

City:

State:

Zip:

Contact:

Tel Number:

Payment:

VISA

Master

AME

Card Holder

Exp. Date:

Card #

Delivery:

*Ship

Will Call

Others

Special Instruction:

Freight:
Total:

* It is the customer’s responsibility for any additional payment for Lift Gate or Inside Delivery services.