SLIPP® ORDER FORM



NO._____________                                                                       DATE:______________

QTY ORDERED______ SIZE_______ @$________ =AMT. DUE $___________

                                                 + SHIPPING $_________=TOTAL$_______________

P.O. NO.____________                                                                                                                   

FOR (Hospital)__________________________________________________

(Address)______________________________________________________

(City/State/Zip)_________________________________________________

CONTACT PERSON:_______________________________________________

DEPT._____________________ PHONE NO.___________________________

PURCHASING CONTACT:___________________ PHONE NO.______________

FAX NO.________________________                                                                                  

BILL TO________________________                                                                                  

                   ________________________                                                                                    

                   ________________________                                                                                    





FOR YOU ORDERING CONVENIENCE THIS FORM MAY BE:

MAILED TO: Wright Products, Inc. P.O. Box 51, Decatur, IL, 62525

PHONED TO: 800-356-6911

FAXED TO: (217) 423-7282

EMAIL: GWSLIPP@AOL.COM WWW.WRIGHTPRODUCTSINC.COM