Print the form
and fax to
(972) 393-8699
or
If payment is by check:
mail the form with the
check payable to:
Global MedNet, Inc.
3527 Oak Lawn Ave.
Suite 614
Dallas, TX 75219
USA
ORDER FORM
First Name:
Last Name:
Specialty:
Address:
City:
State/Province:
Postal Code:
Country:
Telephone:
Fax:
Email:
Price:
US $ 599.00
Quantity:
Subtotal:
Texas
residents:
add 7.75% sales tax
Total:
PAYMENT TYPE:
Check or Money Order
Bill Credit Card
*
Master Card
VISA
AMEX
Name:
Card #:
Exp. Date:
Signature _________________________________
*
If you selected credit card payment, your credit card will not be billed until shipment of the CD.
Online Order Form
(Internet connection required)
For any additional information, send email to
cd-demo@globalmednet.com
or call
(214) 244-7584