NINE    DOLLARS AND NINETY FIVE CENTS      ( $ 9.95 )

PLEASE FILL IN THE INFORMATION BELOW EXACTLY AS IT APPEARS ON YOUR CREDIT CARD STATEMENT.

                                        MASTER  CARD  or  VISA               

                  ITEM        WANTED          HERE  >                 
   
NAME:
   
Address:
CITY:
State:
Zip:
Email:
   
   
CARD NUMBER:  
EXP. DATE:
* CARD CODE NUMBER:
* ON  BACK  OF CARD              HELP CLICK HERE
   
PRICE  :     
 SHIPPING  :     
TOTAL  :      
THANK YOU  !     CHARGES WILL APPEAR  ON YOUR CARD TO :  MEDICAL SUPPLY  COMPANY

        

                                                                                  

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12/22/2013 12:58:08 PM -0500

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