Triple Flu Defense - Sales Rep Form

Date

MM
/
DD
/
YYYY
Rep Name
Prefix
First
Last
Suffix
Customer Information
 New Customer 
 Existing Customer 
Retail Store/
Practitioner Name
Contact Person
Email Address
Phone Number

###
-
###
-
####
Shipping Address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Country
Billing Address
 Same as shipping address 
 Different from shipping address (see below) 
Billing Address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Country

Order Information

Number of units: Minimum order of 6 units required.
1 - 12
Number of cases (12 units)
Custom quantity (12 or more)
Introductory Offer:
POP counter display?
 (initial order of 9 or more units required)  
Special Instructions:

Free Shipping on Orders of 12+ Units and Over, Standard Shipping is $9.95

Payment Information

Please provide the following information. Credit Card information required on initial orders.
Name on card: First, Last
Company Name - if on card
Credit Card Type
 Mastercard 
 VISA 
 American Express 
 Discover 
credit card number
expiration date
3 digit security code
Image Verification
captcha
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