Request for Stock

MEDEQUIP DEPOT

REQUEST FOR STOCK

PLEASE SUBMIT ONE FORM PER ITEM.
We are delighted to consider your request to stock product for repeat orders from your facility. Please note that you are responsible for making sure the information you enter is correct. In case you need to make any changes, please contact us immediately at orders@medequipdepot.com. If by the time you contact us the products have been ordered you are responsible for purchasing a 1 month supply. Thank you and we look forward to working together!
Company Name*
Full Name*

First NameLast Name
E-mail*
Phone Number*

Area CodePhone Number
Manufacturer*
Product Part Number*
Product Description*
Quantity Requested to Stock*
The qty you are requesting us to stock does not have to match identically the qty on each PO.
From Date*

MonthDayYear
To Date (optional)

MonthDayYear
Frequency of Delivery

WeeklyMonthlyEvery 2 MonthsEvery 3 MonthsEvery 6 MonthsOther
Comments
By signing this form:*

I acknowledge that the manufacturer, part number, description, and quantity listed above are correct.I agree that if I did not list an end date for this request, I will send it by email to orders@medequipdepot.com at least 2 months in advance. I commit to purchase 1 month worth of product if I do not communicate the end date by email at least 2 months in advance.I agree to the general terms & conditions of purchase listed at http://www.medequipdepot.com/terms-and-conditions/
Signature*

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