Order Form

Long Term Care Division

Order Form

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Suggestions For:
Arthritis
BedBound
Depression
Mobility Impaired
Vision Impaired
Hearing Impaired

FREE Gift Wrapping!

Shipping only $6.95 per order!
( USA only)

Satisfaction Guaranteed!

To Order:

	Simply call us at 1-800-524-4677, OR...
	Fill out this order form and press . Include your current daytime phone number. We will call you for credit card payment information (USA locations only), OR...
	Fill out this order form and press Print on your Browser tool bar. Mail it to us along with your check or money order.

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Ordered By:
*Name:     (Items in *blue are required.)
*Address:
*City:       *State: *Zip:
*Phone:
*E-Mail:

Ship To: (enter only if different from "Ordered By" above)
Name:
Address:
City:         State:  Zip:
Phone:

Add Shipping & Handling	$ 4.95
Total
Add 4% Sales Tax on Total ^{^{^{(if delivered in Alabama)}}}
Total Due

Comments:

Call us TOLL FREE! 1-800-524-4677

(Prices and availability subject to change without notice.)

Seniors, Inc.™
1225 Wagner Drive
PO Box 1817
Albertville, AL 35950

Phone: (256) 840-1412
Fax: (256) 840-1812