Trapdoor Connecting Tube Order Form

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Trapdoor™ Connecting Tube Order Form
(U.S. Customers) (Canadian Customers)

SHIP TO: (Please Print)
[ ] Address Correction [ ] Different Address

Name: ___________________________________

Address: _________________________________

City: _______________ State: _____ Zip: __________

Telephone Number: __________________________

METHOD OF PAYMENT:
[ ] Check or money order payable to Cook Incorporated
[ ] Credit card order

Card #: ___________________ Exp. Date: __________

Signature: _____________________________________
(Must be signed to be accepted)

Item Description	Item #	Quantity	Price Each	Total Price
Chait Trapdoor ™ connecting tube	CTU-10.0-18-CAA	______	______	______
PHYSICIAN’S SIGNATURE: _____________________________

For U.S. Customers:

To place an order, fill out this form and FAX to
800 554-8335
or call Cook Incorporated, toll-free:
800 457-4500.

In case we have any questions about your order,
please include your telephone number.

2-day Air Delivery is free. Overnight delivery is extra.
We can’t express deliver to a P.O. box.

For Canadian Customers:

To place an order, fill out this form and FAX to
(905) 640-6804
or call Cook Incorporated, toll-free:
800 668-0300.

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