SUPPLY ORDER

LEVY DEVAY, LLC

755 W. Big Beaver Rd., Ste. 2020

Troy, MI 48084

Phone 248-961-5601 / Fax 248-886-8115

CUSTOMER CONTACT:

Account Number: *

Company Name: *

Billing Address: *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Contact Number: *

Area Code Phone Number

E-mail *

SHIP TO:

Full Name: *

First Name Last Name

Shipping Address:

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Same as the Billing Address

Contact Number: *

Area Code Phone Number

E-mail: *

Person Placing Order: *

First Name Last Name

DELIVERY DETAILS:

Estimated Order Amounts: *

10,000 pcs. bulk 20,000 pcs. bulk 30,000 pcs. bulk 40,000 pcs. bulk 12,000 pcs. blister-12 pcs. per pack 24,000 pcs. blister-12 pcs. per pack 48,000 pcs. blister-12 pcs. per pack 60,000 pcs. blister-12 pcs. per pack

Color: *

1. Price: Call or fill in form information for price quote. Price depends on quantity ordered. Blister packs contain 12 caps each.

2. Please fill in customer contact and shipping information above.

3. Please send only one copy of your completed supply order by email, mail, or fax. Phone orders accepted.

4. Enter the information requested in the form table and submit.

5. Levy Devay staff will respond to the supply order with the final delivery dates, terms, delivery method if not chosen, and specifications listed above.

6. Payment due 30 days from receipt of merchandise with advanced credit established. Prepayment on all other accounts or amounts exceeding credit approval limit.

7. Send all correspondence to:
Levy Devay, LLC
755 W. Big Beaver Rd., Ste. 2020
Troy, MI 48084
Phone: 248-961-5601
Fax 248-886-8115
Email: info@levydevay.com