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Purchase order if applicable

TO ORDER OUR MEDICAL OR

QTY OF LABELS REQ

QTY OF LABELS REQ

AL NUMBER

AL NUMBER

QTY OF LABELS REQ

QTY OF LABELS REQ

ALR NUMBER

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TOTAL QTY OF LABELS ORDERED

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Effective 01-07-10

Sorry, No Amex or Diners Cards

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OR CHARGE TO MY ACCOUNT

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If charging to your account

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