COMPACT WITH SUPPLIES – Fieldtex Products Inc.

FIELDTEX ORDER#- LINE: *

CUSTOMER NAME: (IF APPLICABLE) *

COMPACT SERIAL NUMBERS: *

All Serial Numbers that include these lot numbers listed individually or by 00001-00010 Format

PIECES: *

922-99908-TOURNIQUETS-LOT NUMBER: *

Quantity 1 per kit

922-99902-QUICK CLOT-LOT NUMBER: *

Quantity 1 per kit

QUICK CLOT-EXPIRATION DATE: *

933-00286D-CHEST SEAL-LOT NUMBER: *

Quantity 1 per kit

CHEST SEAL-EXPIRATION DATE: *

933-0286E-COMPACT ONLY ISRAELI 4" BANDAGE-LOT NUMBER: *

Quantity 1 per kit

933-00286E-COMPACT ONLY ISRAELI 4" BANDAGE-EXPIRATION DATE *

Quantity 1 per kit

922-00081-EMERGENCY SPACE BLANKET-LOT NUMBER: *

Quantity 1 per kit

922-00146-CPR FACE SHIELD-LOT NUMBER: *

Quantity 1 per kit

922-10492-1 BAG OF GLOVES (10/PK)-LOT NUMBER: *

Quantity 1 per kit

922-04061 UTILITY SCISSORS 5.5”-LOT NUMBER: *

Quantity 1 per kit

KIT ASSEMBLED BY *

KIT CHECKED BY *

Name