Fax/Email order form

Devine Medical Supplies

We Retail at wholesale Prices

 Complete Form and Fax or Mail to:
Devine Medical Supplies
9960 Bell Ranch Drive.
Suite #105
Santa Fe Springs, CA 90670
Fax 562-944-5680

Bill To: Ship To:
Name:*  Name:* 
Address:*  Address:* 
City:*  State:*  Zip:*  City:*  State:*  Zip:* 
Phone:*  Phone:* 
E-mail address*: 

item # color size qty. item description price each total price
* * * * * * *
We appreciate your business.See our returns policy Shipping & Handling (see chart below):
Order Subtotal:
Sales Tax - California Residents Add 8.25%, other states no Tax:
Your Order Total Due:

Shipping Method (check one)*     U.S.A.    International
Shipping and Handling Charges are $.50 per item plus the amount below:
Heavy weight Items. Shipping charges for heavy weight items may be different .Please call us for actual shipping charges on heavy weight items
U.S.A. Order
$0.00 to $49.99 =
$50.00 to$99.99 =
$100 to 199.99 =
$199.99 to $499.99 =
$500 to $999 =
$1000 & above
 		U.S.A. Shipping Cost
$6.50
$9.99
$16.99
$24.99
$49.99
$49.99 + 5% of invoice value
 		Intl. Order
$0.00 to $49.99 =
$50.00 to$99.99 =
$100 to 199.99 =
$199.99 to $499.99 =
$500 to $999 =
$1000 & above
 		Intl. Shipping Cost
$39.99
$49.99
$64.99
$99.99
$149.99
$149.99 + 10% of invoice value

Payment Method USA orders*
Check or Money Order    Visa   Mastercard   American Express   Discover
Payment method for overseas Orders
Only Western Union Money transfer (our company and address given above) or wire transfer
Print Name on Credit Card:*  Credit Card Number:* 
Card Verification Value:*  Expiration Date:* 
Signature:  Today's date:*