Order Date:

_______________________________________________

Dealer:

 Columbus Mobility Specialists, Inc.

Mailing Address:

 6330 Proprietors Road, Suite C

City, State, Zip Code:

 Worthington, Ohio 43085

Authorized Representative

_______________________________________________

Representative Signature

_______________________________________________

Enclosed is our check number __________ in the amount of $__________ to cover the cost of __________ labels at $6.00 per label.  Columbus Mobility Specialists, Inc. will report all labels issued and on-hand using the Monthly Label Use Forms as specified in Appendix I (Label Reporting) of the NMEDA QAP manual for Columbus Mobility Specialists, Inc.  The order is not subject to a refund.  Please allow 15 days from receipt to process label orders.  Remit this form and check to the RADCO Corporate Office (see contact information at the top of this page).

The desired shipping method is checked below

O - UPS Next Day / Early AM
O - UPS Next Day
O - UPS Next Day / Saver
O - UPS 2nd Day / AM
O - UPS 2nd Day
O - UPS 3rd Day Select
O - UPS Ground
UPS Acct: _______________

O - Federal Express Priority
O - Federal Express Standard
O - Federal 2 Day Economy
O - Federal Express Saver 3 Day
Fed Ex Acct: _______________

O - Airborne Express
O - Airborne Next Afternoon
O - Airborne 2 Day
Airborne Acct: _______________

FOR RADCO OFFICE USE:

Issued Label Numbers N-_______________________ through N-_______________________

Date Issued: ____________________

Shipped by: ______________________________________     Date: ____________________

MARIAD CADENA, NMEDA LABEL ADMINISTRATOR

Page Revision Date
12/23/2002

NMEDA QAP
Manual Page 27