Rx Data Systems, Inc - Print & Fax Order Form

Rx Data Systems, Inc.
PO Box 31966                                                     www.rxds.com              Palm Beach Gardens, FL 33420
561-863-7774                                                      800-828-1355                                 561-863-8388 Fax
PRINT & FAX ORDER FORM       -       FAX TO: 1-561-863-8388
Save Money and Time by using this Print & Fax Order Form!

Print this page & fill out your information. Fax it to us. You receive a Print & Fax Discount of $1.00 on your order plus saving your time on the phone. Prices do not include shipping (or Sales Tax for Florida customers) but they will be on the Invoice showing exactly what was charged.

PLEASE PRINT IN ALL CAPS WITH BLACK INK FOR FAXING

Office / Business Name _______________________________________________________
Contact Person _____________________________________________________
Street Address ________________________________________ Suite _____________
City__________________________ ST ____ Zip _________ Fax ________________________
Phone ________________________ Email __________________________________________
(We will Email you a confirmation when we process your order. We do not send any junk Email and we do not give
your Email to anyone else. Read our complete Privacy Policy here.)

Select Payment Method American Express ____ MasterCard ____ Visa ____ Discover ____
Credit Card # _________________________________________________
Exp Date (Month/Year) ______/______ Verification Code ________ (This is the last 3 digit number on the BACK of Visa / Master Card / Discover at the right side of the Signature Panel. On American Express it is a 4 digit number printed on the FRONT of the card. This is required by the credit card companies for transactions where the card is not present.)
If the card is not billed to the Office / Business name and / or address above provide that information below.
Cardholder Name ____________________________________________________
Card Billing Address ___________________________________________________
Suite / Apt _____________City________________________ ST ___ Zip _________
Cardholder Signature (REQUIRED for Discount)__________________________________

Qty	Rx Data Item #	Description - Laser / Bar Code / Etc ?	Price Each	Total for Item





Subtotal for all Items
(If your Products Subtotal is $25 or more this applies) Less Print & Fax Allowance				-$1.00
Total for all Items