FLU VACCINE PRE-BOOK CONFIRMATION

 

TO:                         EMED MEDICAL COMPANY

 

FROM:                 

 

FAX # :                  314-739-6114

 

RE:                         FLU VACCINE PRE-BOOK   2007-2008 

 

Dear Customer:

 

All Pre-Books will be confirmed for orders before shipment

 

Cancellation or change can be made at any time

 

All Shipments are scheduled to begin after October, 15 2007

 

Please sign below to acknowledge your agreement of the terms of this Pre-Book.  Please fax form back to Emed @ 314-739-6114.  Thank You,

 

Eric Bailey

 

PRE-BOOK ONLY --  NOT AN ORDER    

 

Fluvorin Split 5ml 10ds vial By: Chiron

 

Pre- Book Order Amount:   ______________  Vls                                     

 

 

**Please Fax Back Form For Confirmation 314-739-6114

 

Account Information:

 

Facility Name:                 ______________________________________________________________

                 

Address:                 ______________________________________________________________

 

City/State/Zip:                ______________________________________________________________

               

Phone #/ Contact:______________________________________________________________

 

Authorized Signature:     ______________________________ // Date: _________________

 

Please Call or Fax Form:   314-739-6815 Fax 314-739-6114