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New Contact Number 239-424-3765

SECURE Project Master Kit Ordering Form

Organization/Company:

________________________________________
   

Contact Person:

________________________________________
   

Title:

________________________________________
   

Phone Number:

________________________________________
   

Fax Number:

________________________________________
   

Department Name:

________________________________________
   

Street Address:

________________________________________
   

City, State and Zip:

________________________________________
   
Billing address (if different)  
   

How Were You
Referred Here?

________________________________________
   

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
  Fort Myers, FL 33902
   

Purchase Order Number:

____________________________________
   

Visa/Master Card payment:

____________________________________
   

Expiration Date:

____________________________________
   
CVV# (on back)  
   

Name on Card:

____________________________________


For More Information:
Teresa Frank, 239-424-3298, Fax 239-424-4155
E-mail: SHARE-Club@leememorial.org

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