Your Name:          

Business Name:   

Address:               

City:                      

State:                    

Zip Code:               

Contact Name:      

Email:                    

Phone Number:     

Ship-to Address (if different):

Name:                   

Business Name:   

Address:               

City:                      

State:                    

Zip Code:               

     Single jar box: 5x4x4 in. (please indicate quantity)

     Multiple jar box: 7x4x5 in. (please indicate quantity)

Contents Description:
Collecting jars are a standard size: 3 in. tall by 2 3/4 in. diameter.
Boxes are reusable. We enclose a prepaid business reply return label.
The multiple jar box holds three jars comfortably.

     Patient Scrap Mailer Package (please indicate quantity)

Contents Description:
Introductory letter & brochure.
Eight prepaid self-sealing bubble-lined mailers.
All mailers are a standard size: 7 1/2 in. wide by 5 1/4 in. high.

Message: