Order Form - Date:
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PRODUCT

UNIT PRICE
TOTAL PRICE



































Muisano USA, Inc.
Harlingen TX 78552  956-783-1810  muisano@aol.com   muisano.net
Please fill out and fax or e-mail  ( Porfavor llenar los datos e enviar por fax or correo electronico )   

    Doctor / Institution  ____________________________________________________________________
    * Contact Person  _____________________________________________________________________
    * Address  ___________________________________________________________________________
    * City  _____________________________________ Sate ____________________ Zip ______________
    * Telephone  (______) __________________________________________________________________
    Fax  (______) _________________________________________________________________________
  
Payment:   Total Enclosed     $ _______________    Check                 Money Order                  Wire Transfer         
                        Charge Amount    $ _______________    Master Card                VISA             American Express                Discover       

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    * Credit Card No.     _  _  _  _  _  _  _  _  _  _  _  _  _  _  _ _  _  _  _    * Expiration Date _________ / _____

    * Three numbers on the back of the Credit Card  _  _  _       or four on front of Amex  _  _  _  _
    
    * Address  ________________________________________________________________________
                               (Address where credit card statement is mailed if different from above)

     * Authorized Signature  ______________________________________________________________




   SHIPPING ADDRESS IF DIFFERENT FROM THE ABOVE ADDRESS
        ATTENTION                                                                                                                                                                         
        STREET                                                                                                                                                                                
        CITY / STATE / ZIP                                                                                                                                                               
        PHONE / FAX / E-MAIL                                                                                                                                                        


(Fields with an * must be filled out or we will not be able to process the credit card)
All our products have a 30 day money back guarantee. Refunds or Returns must adhere to company policy.
WIRE TRANSFERS:

Muisano USA, Inc.
Frost Bank,  809 Main Street,  Alamo TX 78516,  956-781-2471 -/- Acct.# 360095575  Routing # 114000093

Instruments
Prices and Modifications subject to change without previous notice - Warranties must adhere to company policy - 30 money back guarantee
Colposcopes