Pers nal T uch Name Date Health Care Apparel Facility Name Room No. P.O.Box “230321” Address (No. P.O.Box) Brooklyn, New York 11223 City State Zip Call us at: (718) 375-1703 Phone ( ) Attn: or outside NY toll free (888) 626-1703 Person to contact if we have a question Fax us at: (718) 627-0200 Labeling Yes No (Available only to health care facilities) Amount: www.nursinghomeapparel.com Title: Expiration Date: X Please sign here if you are charging this purchase on your credit card Card Account Number

WOMEN’S CLOTHING ITEM PAGE DESCRIPTION STYLE LETTER QTY. SIZE PRICE TOTAL BUDGET DRESS BACKSNAP F99 15.00 BS POLY/COT HOUSE DRESS F100 20.00 BS POLY/COT HOUSE DRESS F101 20.00 BACK BS POLY HOUSE DRESS F102 20.00 SNAP BS DAYTIME DRESS F103 26.00 DRESSES BS 3/4 DAYTIME DRESS F104 26.00 BS SUNDAY DRESS L/S F105 28.00 BS FANCY BRAIDED DRESS F106 28.00 BIG WOMENS DRESS 3X-5X F138 30.00 BACK SNAP SLIP F110 8.00 BACK SNAP SLIP W/LACE TRIM F111 10.00 SLIPS SLIP W/CUTOUT F112 10.00 EXTRA SIZE SLIPS (46-52) F110XX 10.00 BACK SNAP POLY/COTTON GOWN F115 15.00 GOWNS FLANNEL GOWN F116 16.00 ADAPTIVE JOGGING SET F120 40.00 ADAPTIVE BACK SNAP BLOUSE F121 22.00 ITEMS DROP SEAT SLACKS F122 20.00 BUDGET DUSTER F130 18.00 BETTER DUSTER F131 24.00 CLASSIC DUSTER F135 24.00 3/4 SLEEVE FANCY DUSTER F134 28.00 FRONT DAYTIME DRESS S/S F132 26.00 DAYTIME DRESS S/S (46-52) CLOSURE F132XX 28.00 ZIP FRONT DRESS L/S F133 26.00 DRESSES ZIP FRONT DRESS L/S (46-52) F133XX 28.00 SUNDAY DRESS W/JACKET F136 40.00 SUNDAY DRESS F137 40.00 BIG WOMEN 3X-5X F138 30.00 DRESSY PANTS SET F139 40.00 BUILT UP SLIP F145 9.00 EXTRA SIZE BUILT UP SLIP F146 10.00 SLIPS ADJUSTABLE SLIP F147 15.00 ADJUSTABLE SLIP (46-52) F147XX 17.00 HALF SLIP F148 12.00 POLY/COTTON GOWN F150 15.00 FLANNEL GOWN F151 16.00 SLEEPWEAR PAJAMAS POLY/COTTON F152 16.00 PRINTED NIGHTSHIRT F153 15.00 PAJAMAS FLANNEL F154 16.00 BUTTON BLOUSE F160 16.00 BUTTON BLOUSE (2X-3X) F160XX 18.00 PULLOVER TOP F161 16.00 PULLOVER TOP (2X-3X) F161XX 18.00 ELASTIC WAIST SLACKS F163 20.00 COORDINATES SLACKS F164 23.00 JEANS F165 23.00 SKIRTS F166 23.00 WALKING SHORTS F167 16.00 SHORT SETS F168 30.00 FANCY SHORT SET F169 36.00 WINTUK SWEATER F185 17.00 SWEATERS SWEATER W/POCKETS F186 22.00 PULLOVER SWEATER F187 20.00 BACK SNAP SWEATER F188 24.00 SCRUBS PRINTED WOMEND SCRUB SET F523 30.00 SCRUB TOPS PANTS U524 18.00 WOMEN’S CLOTHING ITEM PAGE DESCRIPTION STYLE LETTER QTY. SIZE PRICE TOTAL COORDINATED SET F178 40.00 FASHION FANCY FLEECE SET F176 40.00 SWEATSUITS SOLID COLOR SWEATSUITS F183 35.00 PRINTED SWEATSUIT F177 40.00 SWEAT TOPS F180 18.00 SWEAT BOTTOMS F179 18.00 FLEECE SET F174 36.00 PANT SET F175 36.00 BACK HOOK BRA F190 12.00 BRAS FRONT HOOK BRA F191 18.00 SPORTS BRA F192 12.00 SPORTS BRA (36-56 DD) F194XX 18.00 TERRY PONCHO ROBE U500 30.00 ROBES TERRY WRAPAROUND F195 30.00 OPEN BACK UNDERSHIRT F200 9.00 OPEN BACK T-SHIRT U513 10.00 OPEN BACK T-SHIRT U513XX 12.00 VEST UNDERSHIRT F201 4.00 VEST UNDERSHIRT (44-52) F201XX 5.00 UNDERWEAR BRIEFS (SIZE 5-10) F202 3.50 BRIEFS (SIZE 11-13) F202XX 4.00 LONG LEG PANTIES F203 4.00 LONG LEG PANTIES (11-14) F203XX 4.50 TERRY BIB W/BARRIER U501 6.00 TERRY BIB U502 4.00 SPECIALTY QUILTED LAP BLANKET F210 14.00 ITEMS QUILTED BED JACKET F212 14.00 JUMPSUITS F213 40.00 MODESTY JUMPSUIT F225 30.00 OPAQUE THI-HI STOCKINGS F215 2.50 THI-HI NONELASTIC F216 2.50 PANTYHOSE F217 2.50 QUEEN SIZE PANTYHOSE F217XX 3.00 HOSIERY COTTON STOCKINGS F218 4.50 KNEE-HI STOCKINGS F219 1.00 KNEE-HI SOCKS F220 2.00 ANKLETS F221 2.00 OVERSIZED CARE SOCKS U503 5.00 SLIPPER SOCKS U504 5.00 SLIPPERS F230 10.00 BOOTIE F231 12.00 ADAP. VELCRO BOOTIE F232 18.00 ADAPTIVE SHOE U505 45.00 FOOTWEAR VELCRO WALKER F238 40.00 LEATHER SHOE F233 40.00 LACE-UP SNEAKER F234 40.00 FASHION BOOTS F235 45.00 VELCRO JOGGER F236 22.00 VELCRO SNEAKER F237 40.00 KNITTED CAP F240 8.00 SCARVES F241 8.00 ACCESORIES GLOVES F242 10.00 HANDBAGS F243 15.00 WINDBREAKER JACKET F250 40.00 3/4 LENGTH COAT F251 70.00 BOMBER JACKET F252 60.00 OUTERWEAR ALL WEATHER COAT F253 90.00 RAIN PONCHO U411 20.00 WINTER PONCHO U507 70.00 Total Amount Goods Sales Tax Authorized Signature GRAND TOTAL (see reverse side for women’s) UNSURE OF SIZES? If you do not know exact sizes, we’ll select the correct sizes for your order if you will give us -- For Men: Neck measurement, waist measurement, and inseam length from closeup in crotch to desired pants length. For Women: Measurement of bust (around shoulder blades, under arms, to fullest part of bust), waist, and hips. FOR WOMEN: BUST inches WAIST inches HIPS inches FOR MEN: NECK inches WAIST inches IN SEAM inches