Horizon Medical Technologies, LLC

Offline Printable Order Form

This order form is provided for customers who prefer to use the traditional offline ordering method or for users who's browsers do not support JavaScript and therefore cannot use our secure online PayPal Payment System.
Click here for online PayPal Ordering Guidelines
Click here for our product ordering information and frequently asked questions.
Complete all the required information, then click the "Print" button at the bottom of the page.

Shipping Information:		Billing Information:
		If Same As Shipping Click Here:
Title/Age:	[ Mr., Mrs., Ms.]	Title/Age:	[ Mr., Mrs., Ms.]
Company Name		Company Name
First Name:		First Name:
Last Name:		Last Name:
Address:		Address:

Apt/Suite #:		Apt/Suite #:
Zip Code:		Zip Code:
City/Town:		City/Town:
Province/State:		Province/State:
Country:		Country:
E-mail:		E-mail:
Telephone:		Telephone:
Fax:		Fax:

Payment Details - Please select a payment method type:

Personal Check	Money Order	Bank Wire Transfer
Company Check	Certified Check	Western Union

Payments should be made out to HORIZON MEDICAL TECHNOLOGIES and mailed or faxed to:

Horizon Medical Technologies, LLC
Dept: Risk Reduction Solutions
904 Bishop Drive
Morgantown, West Virginia
USA 26505

Toll-Free Telephone: 1- 800-296-0482
Local Telephone: 1-304-296-1182
Fax: 1-304-296-1186
E-mail: Info@HorizonMedTech.com
Alternate E-mail: mikead@adelphia.net

List the items that you wish to order....

Catalog#:

Product Name:

Quantity:

Unit Price:

Price:

Multi-Drug Screen Panel Tests: Specify drug combinations below;

Number of Drugs for Screening [up to 10 Combinations]
Yes No Simultaneously test for adulterant urine samples

Sub-Total

Shipping
Charges:

Shipping/Handling charges originate from West Virginia, USA; [Prices Quoted in US$ Currency / Carrier: UPS - United Parcel Service]			Shipping
Ship to U.S.	Ship to Canada	Ship to International
E-Mail/Call for Rate	E-Mail/Call for Rate	E-Mail/Call for Rate
Indicate dollar amount you were quoted for shipping/handling charges;

Sales Tax:

Sales tax will only apply to residents of West Virginia who do not provide a faxed copy of their tax exemption certificate.
Prices are subject to all taxes, excises, or other charges levied by any government (international, national, state, or local) upon the sale, consumption or use of the products.

Sales-Tax

Date:

Signature:

Total $ Amount
[US$ Currency Only]

Please include your signature for authorization on all orders submitted via fax or mail.
Your signed Purchase Order is acceptable for fax orders.
For wire transfers banking information and shipping/handling rates please contact us or call us for details.

Note: All orders will be verified and confirmed via e-mail, phone or fax prior to us processing your payment.
Please enter any notes or special instructions in this section only;

When you have completed all the required information click on the "Print" button below. Or click on the "Clear" button to clear the fields and start again! Please Note: This Order Form is better printed using the Internet Explorer Browser V.5+.