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New Contact Number 239-424-3765
SECURE Project Master Kit Ordering Form
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Organization/Company: |
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Contact Person: |
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Title: |
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Phone Number: |
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Fax Number: |
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Department Name: |
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Street Address: |
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City, State and Zip: |
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| Billing address (if different) |
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How Were You
Referred Here? |
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Street Address: |
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City, State and Zip: |
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| Item Requested |
Unit Cost |
Quantity |
Total |
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| Master Kit (for profit) |
$475.00 |
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$________ |
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| Master Kit (non-profit) |
$425.00 |
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$________ |
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| *mini Kits (set of 5) |
$150.00 |
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$________ |
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| *mini Kits (100 +) |
$25.00/ea |
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$________ |
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| *CD |
$50.00 |
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$________ |
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| *Set of Glasses (5 pair) |
$15.00 |
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$________ |
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| *Gloves (pair) |
$5.00 |
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$________ |
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| *Pens (10) |
$10.00 |
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$________ |
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| *Pill Bottles (10) |
$10.00 |
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$________ |
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| Delivery Charge |
$25.00 |
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$________ |
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Total Cost: |
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*Only available after you
purchase the Master Kit.
Check or
Money Order Payable to: Older Adult Services Department
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Send to: |
Lee Memorial Health System |
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SHARE Club |
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P.O. Box 2218 Suite 807 |
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Fort Myers, FL 33902 |
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Purchase Order Number: |
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Visa/Master Card payment: |
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Expiration Date: |
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| CVV# (on back) |
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Name on Card: |
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For More Information:
Teresa Frank, 239-424-3298, Fax 239-424-4155
E-mail:
SHARE-Club@leememorial.org
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to SECURE Homepage
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