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CUSTOMER/HOSPITAL

CONTACT

PHONE

ADDRESS

CITY

STATE

ZIP

CUSTOMER "NO-CHARGE" PO #(For package tracking and delivery only)

SHIP TO:

PLEASE DO NOT EXCEED (15) INSTRUMENTS

GENERAL/OB/GYN

NEURO/ORTHOPEDIC

MICROSURGICAL

CARDIOVASCULAR/THORACIC

TOTAL INSTRUMENTS SENT

ETCHING/COLOR CODING INSTRUCTION

CUSTOMER COMMENTS/SPECIAL INSTRUCTIONS

DATE

REPRESENTATIVE SIGNATURE

SHIP TO: Five Star Surgical, 163 Samuel Barnet Blvd., New Bedford, MA 02745 PH: (508) 998-1404 www.fivestarcompanies.com