Hampshire County Medical Order Form
MAKE SURE YOU SELECT YOUR CORRECT SIZE, IT AUTO DEFAULTS TO THE SMALLEST SIZE, THERE IS A RUNNING SUBTOTAL AT THE BOTTOM OF THE PAGE. FORM LIMIT OF $950 OR YOU CAN'T SUBMIT
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( X )
Spiewak Softshell with patch/flag/star
S318Z
$
130.00
Quantity
1
2
3
4
5
6
7
8
9
10
Size
XS
SM
MED
LG
XL
2X
3X
LG-TALL
XL-TALL
2X-TALL
3X-TALL
Otto baseball hat with black star
$
15.00
Quantity
1
2
3
4
5
6
7
8
9
10
Blauer skull cap with black star
160
$
32.00
Quantity
1
2
3
4
5
6
7
8
9
10
Size
Reg
OS
Blauer skull cap WITH PONYTAIL SLOT w/ black star
160
$
40.00
Quantity
1
2
3
4
5
6
7
8
9
10
Size
Reg
OS
Flexfit with black star
6277
$
19.00
Quantity
1
2
3
4
5
6
7
8
9
10
Size
S/M
LG/XL
XL/2X
UA Charged Valsetz 8" zip (Men's Sizes Only) (Men's 6 = womens 8)
3027383
$
150.00
Quantity
1
2
3
4
5
6
7
8
9
10
Size
6
6.5
7
7.5
8
8.5
9
9.5
10
10.5
11
11.5
12
13
14
15
UA Stellar Water Proof 8" Zip (Men's Sizes Only) (Men's 6 = womens 8)
3028314
$
120.00
Quantity
1
2
3
4
5
6
7
8
9
10
Size
6
6.5
7
7.5
8
8.5
9
9.5
10
10.5
11
11.5
12
13
14
15
Rocky Alpha Force 6" waterproof boot
2167
$
115.00
Quantity
1
2
3
4
5
6
7
8
9
10
Boot Size
4
4.5
5
5.5
6
6.5
7
7.5
8
8.5
9
9.5
10
10.5
11
11.5
12
13
14
15
Boot Width
Medium
Wide
Rocky Alpha Force 8" Zipper Waterproof boot
2173
$
125.00
Quantity
1
2
3
4
5
6
7
8
9
10
Boot Size
4
4.5
5
5.5
6
6.5
7
7.5
8
8.5
9
9.5
10
10.5
11
11.5
12
13
14
15
Boot Width
Medium
Wide
Rocky Jump Boot (MENS)
2090
$
150.00
Quantity
1
2
3
4
5
6
7
8
9
10
Boot Size
7
7.5
8
8.5
9
9.5
10
10.5
11
11.5
12
13
14
15
Boot Width
Medium
Wide
Rocky Paratrooper Boot (WOMENS)
4090
$
150.00
Quantity
1
2
3
4
5
6
7
8
9
10
Boot Size
5
5.5
6
6.5
7
7.5
8
8.5
9
9.5
10
Rocky Blizzard Stalker 1200 Grams Thinsulate (Men's Sizes Only)
5455
$
140.00
Quantity
1
2
3
4
5
6
7
8
9
10
Size
8
9
10
11
12
13
Original Swat Classic 9" Side Zip (Men's Sizes Only) (men's 4 = Womens 6)
115201
$
125.00
Quantity
1
2
3
4
5
6
7
8
9
10
Size
4
4.5
5
5.5
6
6.5
7
7.5
8
8.5
9
9.5
10
10.5
11
11.5
12
13
14
15
Width
Regular
Wide
Reebok Trailgrip 6" Waterproof Side Zip (Men's sizes only) (Men's 4 = womens 6)
RB3450
$
125.00
Quantity
1
2
3
4
5
6
7
8
9
10
Size
4
4.5
5
5.5
6
6.5
7
7.5
8
8.5
9
9.5
10
10.5
11
11.5
12
13
14
15
Width
Regular
Wide
Reebok Sneaker Boot (Men's sizes only) (Men's 4 = womens 7
RB3450
$
110.00
Quantity
1
2
3
4
5
6
7
8
9
10
Size
4
4.5
5
5.5
6
6.5
7
7.5
8
8.5
9
9.5
10
10.5
11
11.5
12
13
14
15
Width
Regular
Wide
Hane's Black Cotton Beefy T-Shirt (unisex)
5180
$
9.00
Quantity
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Size
SM
MED
LG
XL
2X
3X
4X
Hane's Cool Dri T-Shirt (unisex)
4820
$
13.00
Quantity
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Size
SM
MED
LG
XL
2X
3X
4X
Jeerzees Sweatpants
973
$
20.00
Quantity
1
2
3
4
5
6
7
8
9
10
Size
SM
MED
LG
XL
2X
3X
Jerzees Hoodie
996
$
25.00
Quantity
1
2
3
4
5
6
7
8
9
10
Size
SM
MED
LG
XL
2X
3X
Jerzees Crew Neck Sweatshirt
562
$
18.00
Quantity
1
2
3
4
5
6
7
8
9
10
Size
SM
MED
LG
XL
2X
3X
Soffee sweatshort
774
$
12.00
Quantity
1
2
3
4
5
6
7
8
9
10
Size
SM
MED
LG
XL
2X
3X
UA Training Shorts
1306443
$
24.00
Quantity
1
2
3
4
5
6
7
8
9
10
Size
SM
MED
LG
XL
2X
3X
3 Pack Crew Socks
285
$
13.00
Quantity
1
2
3
4
5
6
7
8
9
10
Rothco Cotton Calf Sock
6180
$
7.00
Quantity
1
2
3
4
5
6
7
8
9
10
3 Pack Low Cut socks
264
$
13.00
Quantity
1
2
3
4
5
6
7
8
9
10
GFP Winter Glove
7318
$
33.00
Quantity
1
2
3
4
5
6
7
8
9
10
Size
XS
SM
MED
LG
XL
2X
Perfect-Fit Neoprene Glove
PFU-1
$
20.00
Quantity
1
2
3
4
5
6
7
8
9
10
Size
XS
SM
MED
LG
XL
2X
Turtleskin Alpha Needle Resistant Gloves
$
85.00
Quantity
1
2
3
4
5
6
7
8
9
10
Size
XS
SM
MED
LG
XL
2X
3X
Perfect Fit 1.75" leather belt
13SS
$
30.00
Quantity
1
2
3
4
5
6
7
8
9
10
Belt Size
28
30
32
34
36
38
40
42
44
46
48
50
52
Boston Leather Velcro Belt
$
45.00
Quantity
1
2
3
4
5
6
7
8
9
10
Size
28
30
32
34
36
38
40
42
44
46
48
Rothco Heavy Duty Range Belt
44799
$
20.00
Quantity
1
2
3
4
5
6
7
8
9
10
Size
SM
MED
LG
XL
Streamlight Microstream
$
23.00
Quantity
1
2
Streamlight DC car adapter
$
14.00
Quantity
1
2
3
4
5
6
7
8
9
10
Heavy Duty Metal Key Holder
KC-B
$
10.00
Quantity
1
2
3
4
5
6
7
8
9
10
Silver Key Holder
39N
$
4.00
Quantity
1
2
3
4
5
6
7
8
9
10
JayPee Double Key Holder
SKH2
$
25.00
Quantity
1
2
3
4
5
6
7
8
9
10
GEN 7 Cat Tourniquet
$
35.00
Quantity
1
2
3
4
5
Clear Bag
$
1.50
Quantity
1
2
3
4
5
6
7
8
9
10
Fisher Space Pen Gold
$
25.00
Quantity
1
2
3
4
5
6
7
8
9
10
Fisher Space Pen Silver
$
25.00
Quantity
1
2
3
4
5
6
7
8
9
10
Space pen refill
$
10.00
Quantity
1
2
3
4
5
6
7
8
9
10
CPR Pocket Mask
$
27.00
Quantity
1
2
3
4
5
6
7
8
9
10
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