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Dalton Medical Authorized Dealer Order Form
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DALTON MEDICAL CORPORATION

1103 VENTURE COURT, CARROLLTON TX, 75006
TEL: (972) 418-5129 FAX: (972) 416-4220

Date (MM/DD/YY):        /        /               New Customer     OR
Order Person:                                 Existing Comp#:                               

Bill To:                                                                PO #:                         
Address:                                                                                                         
City:                                   State:                      Zip:                     
Phone Number:                                   Fax Number:                                  
 
If different from above --
Ship To:                                                                                                         
Shipping Address:                                                                                                         
City:                                   State:                      Zip:                     
Contact:                                   Tel Number:                                  
 
Payment: VISA Master AME Card Holder             Exp. Date:      /      Card #           
Delivery: *Ship                         Will Call                         Others                        

QTY Item # Description Unit Price Extended Price
         
         
         
         
         
         
         
         
         
         
Special Instruction: Freight:  
Total:  
* It is the customer’s responsibility for any additional payment for Lift Gate or Inside Delivery services.
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