Glove Management

Full Name *

First Name Last Name

Phone Number *

Area Code Phone Number

E-mail *

Is your bill to and ship to address the same? *

Yes No

Ship To *

Bill To *

Do you currently have gloves? *

Yes No

Do you currently have a second set of gloves? *

Yes No

Would you like shipping charges billed to your FedEx or UPS account? *

Yes No

Fedex Account #

UPS Account #

Do you want serial number identification markings on the gloves? *

Yes No

I would like to... *

Have 70E Solutions generate serial numbers Provide serial numbers to 70E Solutions

Do you want your gloves to be on a two-color rotation? *

Yes No

Do you authorize replacements for failures? *

Yes No Send me a quote

In the following area please tell us what gloves you'd like to receive every six months

Quantity

Class

Color

Size

Serial Number (OPTIONAL)

1

2

3

4

5

6

7

8

9

10

Additional Questions/Comments