NMEDA QAP LABEL ORDER FORM

 RADCO, 3220 E. 59TH STREET, LONG BEACH, CA 90805 TEL: 562‐272‐7231 FAX: 562‐529‐7513 EMAIL: label‐[email protected] NMEDA QAP LABEL ORDER FORM NOTE: A label may only be affixed to a vehicle which has been modified under the NMEDA Quality Assurance Program. By ordering labels, the dealer certifies that all necessary inspections and requirements of the NMEDA Quality Assurance Program will be carried out. Label use is reported monthly in accordance with the QAP Rules. Date: Dealer Name: Mailing Address: City, State/Province, Zip: Authorized Rep: PAYING BY CHECK make your check payable to “RADCO”, complete this form and mail, fax or email it to RADCO at the address on the top of the form. Enclosed is our check, number ____________in the amount of $ ___________ USD to cover the cost of ___________ labels at $2.00 USD per label. PAYING BY CREDIT OR DEBIT CARD ON RADCO’S WEB SITE . Go to RADCO’s web site at www.RADCOInc.com, under the OUR SERVICES tab click on Mobility Equipment Vehicles. Click on the BUY NOW button and following the instructions. Complete this form and mail, fax or email it to RADCO at the address on the top of the form. Payment to PayPal was made in the amount of $ ___________ USD (includes 5% handling fee) to cover the cost of ___________ labels at $2.00 USD per label. This order is not subject to a refund. Orders will be filled if the dealer is in good standing and has no outstanding balance due to RADCO. Please order enough labels for an estimated three month usage. Allow 15 days from receipt to process & receive label orders. Ship Via (Check One and include your account number): If no account is provided, RADCO will invoice for shipping cost plus a $15 billing fee. UPS Next Day/Early AM UPS Next Day UPS Next Day/Saver UPS 2nd Day UPS 3 Day Select UPS Ground Federal Express Priority Federal Express Standard Federal 2 Day Economy Federal Express Saver 3 Day Federal Express Ground DHL Express Fed Ex Acct. No: DHL Acct. No: UPS Acct. No: FOR RADCO OFFICE USE ONLY through Issued Label No’s: (USA) N‐ (Canada) NC‐ Total Issued: Shipped by: QAP‐F05 (C) – NMEDA QAP Label Order Form through N‐ NC‐ NMEDA LABEL ADMINISTRATOR Date: