March 25, 2007

Flu Vaccine Survey Form

Glaxo Fluarix Vaccine for sale this year

Account Name:_______________________________

Number of doses requested:_____________________

Note:  Fluarix is packed 5 syringes per box @ 12.33 per dose

Product will be shipped in September

Please fill out this form and Fax it to: (802) 893-5026.

Or

Call Customer Service at (800) 338-8703