Supply Form | Figment Group Inc.

Instructions

Shipping & Handling Charges will be added to your total purchase.

Please complete the order form completely.

To select an item, choose your quantity.

To submit your order, please click on the Captcha—–I am not a robot box, then click the Submit Order button at the bottom of the form.

For equipment and supplies not listed on this order form, please contact Figment Group, Inc. at 219.326.8880 or by E-mail.

Company / Clinic *

Name of Individual Placing Order *

Email *

Phone *

Shipping Address *

Attention *

Billing Address *

Shipping Method *

Normal - 5 to 7 Business Days

Next Business Day - Extra Fee

P.O. Number

Phoenix 6.0 EasyTab (100 pcs/pkg) - Your Cost: $23.60/pkg

Part No. 13043 - List: $24.60/pkg

Phoenix 6.0 EasyTab (250 pcs/pkg) - Your Cost: $56.45/pkg

Part No. 13046 - List: $58.45/pkg

DOT Forms (Perforated Top - 100/pkg) - Your Cost: $26.00/pkg

Part No. 14010 - List: $27.30/pkg

Non-DOT Forms (Perforated Top - 100 /pkg) - Your Cost: $26.00/pkg

Part No. 14008 - List: $27.30/pkg

PermAffix Printer Labels (140 labels/roll) - Your Cost: $23.45/roll

Part No. 14107 - List: $25.45/roll

PermAffix Printer Labels (4 roll pack) - Your Cost: $81.95/roll

Part No. 14197 - List: $83.95/roll

Bluing Tablets (100 Tablets) - Your Cost: $13.29/bottle

Part No. 19003 - List: $14.29/bottle

Bluing Tablets (3 pk-100 Tablets Each) - Your Cost: $35.86/3-pk

Part No. 19064 - List: $37.86/3-pk

.040 Dry Gas Cylinder (34 liter) - Your Cost: $132.00/cyl

Part No. 15011 - List: $141.00/cyl

.100 Dry Gas Cylinder (34 liter) - Your Cost: $132.00/cyl

Part No. 15005 - List: $141.00/cyl

Calibration Adapter Kit - Your Cost: $4.95/kit

Part No. 15308 - List: $5.15/kit

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