REQUEST INVOICE OB5 (109)

Please enter on this form (OB5) the details that you want on the invoice and your details for reference.

PLEASE PROVIDE DETAILS RE THE PURCHASING ENTITY:

Purchasing Company *

Principal Contact First Name *

Principle Contact Last Name *

Principle Contact Phone Number *

Principal Contact Email (person to be sent the invoice) *

Second Persons Email on Invoice (2nd person to be sent the invoice -optional)

DETAILS TO GO ON THE INVOICE:

Building Number & Street *

County/State *

City/Town *

Zip/Post Code *

Country *

ALTERNATIVE DELIVERY ADDRESS

Purchasers Website

PLEASE PROVIDE DETAILS REGARDING THE CARE FACILITY THAT WILL BE USING REME:

Name of Care Facility *

Responsible Manager at Care Facility *

LIST THE ITEMS TO BE PURCHASED AND PRICE AGREED FOR EACH - LINE BY LINE, AND DEFINE ANY DISCOUNTS PROVIDED: PROVIDE THE TOTAL INVOICE COST AND THE VAT COMPONENT

Add the number of years licences to be included in invoice, any special requirements and any delivery advice.

OTHER ITEMS:

On receipt of payment ReMe will be activated within 3 working days.

Payment Date

Your Purchase Reference Number

Are you subject to VAT?

PLEASE PROVIDE DETAILS OF THE PERSON WHO INTRODUCED REME TO YOU (optional):

Introducers First Name

Introducers Second Name

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