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Secure LASER Prescription Paper - New Jersey Format

ORDER FORM
~This is a SECURE Order Form ~

Micro Format, Inc. along with our Manufacturing Partner Printco
is an approved NJ Pharmacy Board Security Prescription Paper Printer

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Micro Format Imprinted Laser Prescription Paper
meet all of the requirements legislated by the State of New Jersey.

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Imprinting Information for New Jersey Laser Prescription Paper
and your Credit Card Payment Information will be requested
AFTER you have clicked on the "Add to Your SHOPPING CART" button
Due to State of New Jersey Regulations ~ Unimprinted forms are not available ~

When Requested,
Please accurately fill-in the information that needs to be imprinted on the top of each sheet.

NEW JERSEY LAW REQUIRES:

• The License Number and NPI# to be printed for each doctor listed.
  
• Only ONE LOCATION may appear on the front of the script.
• We have been notified by the State of New Jersey ....
  All doctor's names MUST be printed on the front of the script.
  The font "point size" can be no smaller than 7pt.
  Thus the imprint format we must use contains:
  The Practice Name, up to THREE (3)doctors names,
  license number, NPI number and (optional) DEA Number,
  address and telephone number.
• Printing additional locations on the back of the script is available
  at an additional charge of $25.00 per 1000.
  This charge will be added to the total price of your order.
  
• Additional names MAY NOT be printed on the back of the script.

• Effective 2009 (immediately),
  New Jersey Law requires that all Rx Scripts be consecutively numbered

VERY IMPORTANT New Jersey State Law requires that all Rx Paper Orders are shipped to the address on file with the State of New Jersey. After submitting your order ..... the Micro Format Compliance Department requires that you send a copy of your State License to our customer service department by FAX FAX Number (847)520-0197 Orders will be processed ONLY after we have received a copy of your State License by fax. Failure to send your License will delay the production of your order. We appreciate your co-operation with this requirement.

New Jersey Laser Prescription Forms Format #1 (MD,DO,DS,DMD,DPM,DVM) Imprint up to 4 Names or 2 Names plus Facility Name Each name must be imprinted with License # and NPI #
ENLARGE VIEW Item# NJMD1 8-1/2" x 11" One Script-Top Left Script Size 4" x 5-1/2" To order ........ Click On "Add to Shopping Cart" 2,500 sheets $435.00 plus shipping by UPS 5,000 sheets $650.00 plus shipping by UPS 10,000 sheets $1,060.00 plus shipping by UPS	ENLARGE VIEW Item# NJMD2 4" x 11" Two Scripts Over/Under Script Size 4" x 5-1/2" To order ........ Click On "Add to Shopping Cart" 5,000 sheets $500.00 plus shipping by UPS 10,000 sheets $725.00 plus shipping by UPS	ENLARGE VIEW Item# NJMD4 8" x 11" Four Scripts per sheet Script Size 4" x 5-1/2" To order ........ Click On "Add to Shopping Cart" 2,500 sheets $485.00 plus shipping by UPS 5,000 sheets $700.00 plus shipping by UPS 10,000 sheets $1,120.00 plus shipping by UPS
New Jersey Laser Prescription Forms Format #2 (MEDICAL FACILITY) Imprint the Facility Name, Address and Phone Number. Only ONE LOCATION may appear on the front of the script. One Doctor's Name, NPI# and License Number must appear on script. Additional locations may be printed on back of the script (at an additional charge).
ENLARGE VIEW Item# NJHC1 Script Size 4" x 5-1/2" 8-1/2" x 11" One Script-Top Left To order ........ Click On "Add to Shopping Cart" 2,500 sheets $435.00 plus shipping by UPS 5,000 sheets $650.00 plus shipping by UPS 10,000 sheets $1,070.00 plus shipping by UPS	ENLARGE VIEW Item# NJHC2 4" x 11" Two Scripts Over/Under Script Size 4" x 5-1/2" To order ........ Click On "Add to Shopping Cart" 5,000 sheets $500.00 plus shipping by UPS 10,000 sheets $725.00 plus shipping by UPS	ENLARGE VIEW Item# NJHC4 8" x 11" Four Scripts per sheet Script Size 4" x 5-1/2" To order ........ Click On "Add to Shopping Cart" 2,500 sheets $485.00 plus shipping by UPS 5,000 sheets $700.00 plus shipping by UPS 10,000 sheets $1,120.00 plus shipping by UPS
New Jersey Laser Prescription Forms Format #3 (OPTICIAN) Imprint maximum 4 Names or 3 Names plus Facility Name. Each name must be imprinted with License # and NPI #
ENLARGE VIEW Item# NJOP1 8-1/2" x 11" One Script-Top Left Script Size 4" x 5-1/2" To order ........ Click On "Add to Shopping Cart" 2,500 sheets $435.00 plus shipping by UPS 5,000 sheets $650.00 plus shipping by UPS 10,000 sheets $1,070.00 plus shipping by UPS	ENLARGE VIEW Item# NJOP2 4" x 11" Two Scripts Over/Under Script Size 4" x 5-1/2" To order ........ Click On "Add to Shopping Cart" 5,000 sheets $500.00 plus shipping by UPS 10,000 sheets $725.00 plus shipping by UPS	ENLARGE VIEW Item# NJOP4 8" x 11" Four Scripts per sheet Script Size 4" x 5-1/2" To order ........ Click On "Add to Shopping Cart" 2,500 sheets $485.00 plus shipping by UPS 5,000 sheets $700.00 plus shipping by UPS 10,000 sheets $1,120.00 plus shipping by UPS