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Ordering Form<br />
Customer Account#<br />
Customer Name:<br />
Specialty:<br />
Date: ____/____/____<br />
___________________________<br />
Representative taking order<br />
Bill To:________________________________________________<br />
______________________________________________________<br />
______________________________________________________<br />
Customer P.O. #:_______________________________________<br />
Method of Shipment: _____FedEx _____UPS<br />
Phone #: (<br />
)______________________________________<br />
Ship To:______________________________________________<br />
______________________________________________________<br />
______________________________________________________<br />
Phone #: ( )______________________________________<br />
Would you like to receive information via email about<br />
<strong>BIOMET</strong> <strong>3i</strong> <strong>Product</strong>s, Services and Events?<br />
n Yes n No<br />
Email Address: __________________________________<br />
Special Instructions:<br />
_____Next Day by 8:30am<br />
_____Next Day by 10:30am<br />
_____Next Day - Afternoon<br />
_____Two Day<br />
_____Ground<br />
_____Other_____________<br />
Method of Payment:<br />
n Credit Card: _____Visa _____MasterCard _____AMEX<br />
Card #:____________________________________________<br />
Expiration Date:_____________________________________<br />
n C.O.D.<br />
Contact Name:<br />
n Bill - Net 30<br />
<strong>Product</strong> No. Quantity Description Discount Unit Price Total<br />
Date: Order Number: Order Total: Customer Service Representative:<br />
<strong>BIOMET</strong> <strong>3i</strong><br />
4555 Riverside Drive<br />
Palm Beach Gardens, FL 33410<br />
Phone: 800-342-5454 • Fax: 561-776-1272<br />
Website: www.biomet<strong>3i</strong>.com<br />
Thank you for your patronage!<br />
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