LLOYD TABLE COMPANY ORDER FORM
102-122 West Main Street P.O. Box 899 Lisbon, IA 52253
800.553.7297 Fax# 319.455.2166 email: sales@lloydtable.com

Sold To:                  P.O.#
Name:
Address:
City:
State:                        Zip Code:
Phone:
Fax:
Email:
 
Doctor/Clinic:
* Name:
* Address:
* City:
* State:                        * Zip Code:
* Phone:
Fax:
Email:

QTY:
* Table:
* Table Width:  Wide(21")            Narrow(18½")
* Gonadal Notch:  Yes                        No
* Height:                   * Color:       
Price:$_______________________

*Table orders will not be processed unless all information indicated by an asterisks.

  Option:   Price:  
  Option:   Price:  
  Option:   Price:  
  Option:   Price:  
  Option:   Price:  
  Option:   Price:  
  Option:   Price:  
  Option:   Price:  
Option: Price:  
                Sub Total: $_______________
Date: __________________ Priority Rush(10% of Total Retail Price) $_______________

Shipping Instructions: __________________________________
 
Prepaid Shipping: $________________

International Surcharge: (Please Call)

Total Due: $______________________
 
 
Signiture: