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SHOE ORDER FORM

Cust. No: / P.O. #: / Date: / Contact:
Bill To: / Ship To:
Address: / Address:
Address: / Address:
City: / City:
State: / Zip: / State: / Zip:
Tel: / Fax: / Email:
Men’s styles are available in sizes: 7, 7½, 8, 8½, 9, 9½, 10, 10½, 11, 11½, 12, 13, 14
Model / Color / Price / Model / Color / Price / Model / Color / Price / Model / Color / Price / Model / Color / Price / Model / Color / Price
410** / Black / $62.50 / 465 / Black / $62.50 / 517 / Black / $62.50 / 572 / Brown / $62.50 / 640* / White / $62.50 / S331 / Tan / $37.00
420 / Brown / $62.50 / 467 / Brown / $62.50 / 520 / Brown / $62.50 / 581 / Black / $70.00 / 641* / Black / $62.50
422 / Brown / $62.50 / 481 / Black / $70.00 / 525** / Black / $51.50 / 582 / Brown / $70.00 / 644 / Brown / $62.50
510** / Black / $62.50 / 571 / Black / $62.50 / 585 / Black / $62.50 / 650* / White / $62.50
573 / Brown / $60.50 / 587 / Brown / $62.50 / 651* / White / $62.50
610 / White / $62.50
*Available also in Narrow (N=B) width
**Available also in size 15, as well as in Narrow (N=B) and XX Wide (XXW=6E) widths / All Men’s styles available in Medium (M=D), Wide (W=2E) Extra Wide (XW=4E) widths
Women’s styles are available in sizes: 5, 5½, 6, 6½, 7, 7½, 8, 8½, 9, 9½, 10, 10½, 11, 11½, 12
Model / Color / Price / Model / Color / Price / Model / Color / Price / Model / Color / Price / Model / Color / Price / Model / Color / Price
701* / Black / $62.50 / 814 / Brown / $62.50 / 851 / Black / $62.50 / 859 / Red / $62.50 / 874 / Brown / $62.50 / 910* / Wt+Blue / $62.50
704 / Taupe / $62.50 / 817** / Black / $62.50 / 853 / Grey / $62.50 / 864 / Brown / $58.00 / 875 / Blue / $60.50 / *916** / Wt+Pink / $62.50
708 / White / $62.50 / 818 / Brown / $62.50 / 854 / White / $62.50 / 865** / Black / $58.00 / 877 / Black / $62.50 / 940* / White / $62.50
810* / Black / $62.50 / 824* / Taupe / $51.50 / 855 / Blue / $62.50 / 871 / Black / $62.50 / 878 / Camel / $62.50 / 941* / Black / $62.50
812 / Black / $62.50 / 825* / Black / $51.50 / 856 / Pink / $62.50 / 872 / Mocha / $62.50 / 879 / Red / $62.50 / 950* / White / $62.50
826 / Blue / $51.50 / 873 / Tan / $60.50 / 881 / Black / $67.00 / S731 / Tan / $37.00
827* / Black / $51.50
*Available also in XX Wide (XXW=4E) width
** Available also in Narrow (N=A) width / All Women’s styles are available in Medium (M=B), Wide (W=D)
and Extra Wide (XW=2E) widths
STYLE / WIDTH / SIZE / NUMBER OF INSERTS / PATIENT’S NAME / REFERENCE NUMBER COMMENTS / TOTAL PER LINE ($)
PRICES: 1. Shoes – See above. 2. Diabetic Inserts - $10.50 a pair. 3. OrthoStep Insoles - $12.50 a pair ($5.50 if ordered with shoes)
Visa/MasterCard: / Exp. Date:
Name on Card: / Signature:
/
SHOE ORDER FORM

Cust. No: / P.O. #: / Date: / Contact:
Attn: / Ship To:
Attn: / Address:
Address: / Address:
City: / City:
State: / Zip: / State: / Zip:
Tel: / Fax: / Email:
CHOOSE FROM: MEN’S STYLE (410 – 651) OR WOMEN’S STYLES (701 – 950)
Size Availability ► / Women’s Sizes Only / Men’s Or Women’s Sizes / Men's Sizes Only
Style / Width / Product / 5 / 5½ / 6 / 6½ / 7 / 7½ / 8 / 8½ / 9 / 9½ / 10 / 10½ / 11 / 11½ / 12 / 13 / 14 / 15 / Total
701 / XW / Shoes / 1 / E X A M P L E / 1 / 2
Diab. Inserts / 3 / E X A M P L E / 0 / 3
510 / W / Shoes / 1 / E X A M P L E / 1 / 2
Diab. Inserts / 3 / E X A M P L E / 1 / 4
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PRICES:
TERMS: / Shoes – See above.
Diabetic Orthotics - $10.50 a pair.
OrthoStep Orthotics- $12.50 a pair ($5.50 if ordered with shoes).
New accounts C.O.D. or Credit Cards. Prices are subject to change without notice.
Prices do not include shipping and handling charges. / Sub Total ($)
Shipping & Handling ($)
GRAND TOTAL ($)
Visa/MasterCard: / Exp. Date:
Name On Card: / Signature: