Seasonal Influenza Vaccination Form

« The vaccines belong to those who get up early ! »

Name of the company:
Division:

Email:
Telephone:
Fax:

Contact person:
Authorized representative:

Advertising

Enter the information that will appear on the advertising poster.

Name of the Company:
Address:

Enter the dates you choose (MM/DD/YYYY)

1st choice:
2nd choice:
3rd choice:

Choose the schedule that suits you better (Allow some time for lunch)

Starting at:
9:00 am
10:00 am
11:00 am
12:00 am

Choose your package by indicating the quantity desired.

The quantities are limited! Please reply promptly in order to reserve the vaccines.

Package 60	Package 50	Package 40
F60-A $1550 Complete package Quantity Nurse Training of the nurse Vaccination length of 7 hours 60 vaccines Medical supplies Informative Material 3 posters 11x17 250 color bagstuffers	F50-A $1390 Complete package Quantity Nurse Training of the nurse Vaccination length of 6 hours 50 vaccines Medical supplies Informative Material 3 posters 11x17 250 color bagstuffers	F40-A $1230 Complete package Quantity Nurse Training of the nurse Vaccination length of 5 hours 40 vaccines Medical supplies Informative Material 3 posters 11x17 250 color bagstuffers
F60-B $1460 Package without advertising Quantity Nurse Training of the nurse Vaccination length of 7 hours 60 vaccines Medical supplies Informative Material	F50-B $1300 Package without advertising Quantity Nurse Training of the nurse Vaccination length of 6 hours 50 vaccines Medical supplies Informative Material	F40-B $1140 Package without advertising Quantity Nurse Training of the nurse Vaccination length of 5 hours 40 vaccines Medical supplies Informative Material
F60-C $1215 Package without nurse Quantity 60 vaccines Medical supplies Informative Material 3 posters 11x17 250 color bagstuffers	F50-C $1055 Package without nurse Quantity 50 vaccines Medical supplies Informative Material 3 posters 11x17 250 color bagstuffers	F40-C $895 Package without nurse Quantity 40 vaccines Medical supplies Informative Material 3 posters 11x17 250 color bagstuffers