|
|
SECURE PROJECT MASTER KIT ORDERING FORM
|
Organization/Company: |
|
|
|
Contact Person: |
|
|
|
Title: |
|
|
|
Phone Number: |
|
|
|
Fax Number: |
|
|
|
Department Name: |
|
|
|
Street Address: |
|
|
|
City, State and Zip: |
|
|
How Were You
Referred Here?: |
|
|
|
Billing address (if different)
|
|
Street Address: |
|
|
|
City, State and Zip: |
|
|
| ITEM
REQUESTED |
Unit
Cost |
Quantity |
|
|
Total
|
| Master Kit (for profit) |
$475.00 |
|
|
$ |
|
|
|
|
| Master Kit (non-profit) |
$425.00 |
|
|
$ |
|
|
|
|
| *mini Kits (set of 5) |
$150.00 |
|
|
$ |
|
|
|
|
| *mini Kits (100 +) |
$25.00/ea |
|
|
$ |
|
|
|
|
| *CD |
$50.00 |
|
|
$ |
|
|
|
|
| *Set of Glasses (5 Pair) |
$15.00 |
|
|
$ |
|
|
|
|
| *Gloves (pair) |
$5.00 |
|
|
$ |
|
|
|
|
| *Pens (10) |
$10.00 |
|
|
$ |
|
|
|
|
| *Pill Bottles (10) |
$10.00 |
|
|
$ |
|
|
|
|
|
|
|
| Delivery charge |
$25.00 |
|
|
$ |
|
|
|
|
|
Total Cost: |
|
$ |
|
| |
|
|
*Only available after you purchase the Master Kit.
Check or Money Order Payable to: Older Adult Services Department
Send to: Lee Memorial Health System
SHARE Club
P.O. Box 2218
Suite 807
Ft. Myers, FL 33902
|
Purchase Order Number: |
|
|
|
Visa/Master Card payment: |
|
|
|
Expiration Date: |
|
|
|
Name on Card: |
|
|
For More Information:
Teresa Frank, (239) 772-6298, Fax (239) 772-6585,
Email: SHARE-Club@leememorial.org
Return to SECURE
Homepage
|
