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FRANKLIN PODIATRY SUPPLY

123 GARFIELD Street

GARDENCITY, NY 11530

TELEPHONE #1-800-972-7917

FAX # 1-516-783-8900

EMAIL: frankdent@aol.com

ORDER-FORM

Product	Item	Description	Price	Qty.	Total
				Subtotal
				Tax
				Total

Name
Address
City		State
Country		Zip
EMAIL & TELEPHONE #

Name
Address
City		State
Country		Zip
Email

Billing Information

Credit card
Name on Card
Card number
Expiratio n