Stalagmite Dental Model System     866-331-2742  Phone
                                                               520-908-3296 Fax          

              Customer Order Form Date:
Business: Phone #
Address-1: Fax #
Address-2: P.O. #
City/State/Zip: Email:
Quantity        Part Code                                Comments

                     Bases come in bags of  50        Mounting-Plates bags of  5         Pins in bags of 1,000
Example: 200 RTP-8 (equals 4 bags of 50)       30 MP-8 (6 bags of 5)      3,000 TDP-1 (3 bags of 1,000)

         ----- Faxing is an efficient way to place an order. -----
1. Print a copy of this order form and fill in all Customer information.
2. Make a Master copy and use it to generate extra copies when needed.
3. Enter Quantity and Part Code and Fax it to us. We will Date Stamp it as Received and Fax you a copy.
 Make sure you receive a Date Stamped copy from us to insure receipt of your order.
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