RxActuator Order Form Order Form Shipping Details Ship To: Ship To is required. Street Address: Street Address is required. City: City is required. State: Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State is required. Zipcode: Zipcode is required. Customer Phone: Format: 123-456-7890 Valid Phone number is required. Please follow the format. Customer Email: Valid Customer Email is required. Purchase Order#: Bill To Company Name: Company Name is required. Street Address: Street Address is required. City: City is required. State: Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State is required. Zipcode: Zipcode is required. Customer Phone Number: Format: 123-456-7890 Valid Phone number is required. Please follow the format. Accounts Payable Email: Valid Email is required. Description quantity Price each Total Mini-Infuser SC-CRI pumps $75.00 Wearable Vest XXS $33.00 Wearable Vest XS $34.00 Wearable Vest M $36.00 Wearable Vest L $37.00 Wearable Vest XL $38.00 Shipping $25.00 Order Total Submit If you have any questions concerning this ordercontact Doug Nutter 810-964-3248 dnutter@rxactuator.net Make all checks payable to RxActuator, Inc. Send payments to: RxActuator, Inc2100 N. Wilmot Rd. Suite 310Tucson, AZ 85712 Terms: Net 30 days