Please provide the following ordering information
First name:   Last name:   Email:   Phone:  Street:   City:   State:   Zip Code:   Discount coupon enter code:   Discounts will be refunded back to your Credit Card or PayPal
Scrub SKIRT $27.00
Price: $27.00   Solid Color: None Aqua Black Brown Burgundy Caribbean Ceil blue Charcoal Denim Forest Galaxy blue Gold Hot pink Hunter green Jade Kelly green Khaki Lilac Mint Navy blue Olive Orange Pink Purple Red Rose Royal blue Sage Silver Sky blue Tan Teal Violet White Yellow
Options: Waist Style:  Drawstring Elastic Cargo Pockets:   None Left Side Right Side Both Sides Side Seam Pockets: None Yes     Back Pockets: None Left Side Right Side Both Sides   Measurements:  Length:   Waist:     Hip:    Width of bottom of Shirt:   Note: How to measure the width of the bottom of the skirt.  Measure from seam to seam at the bottom of the skirt when lying flat, not doubled
Appliques $2.00   Price: None $2.00      Appliques: None 20996 20998 21000 21003 21007 21009 4983 4940 5804 5806 5807 5810   Please specify, where Appliques to be placed in the "Special Request" box
Special Request, code and/or questions:	Please complete the following questions, so we can improve our services.       How do you like to wear your scrubs?  NA Loose Fitting Form Fitting  How did you hear about us? None yellow pages face book twitter friend google yahoo msn postcard email other     Other:  Are you a returning customer:    If so, use existing measurements:   Do you want to be notified of new fabrics or specials: yes no  Join the Birthday Club & receive discount:     Birth Date: xx-xx-xx

Please "Print Copy" for your records prior to submitting order.