Medtronic Latin America Product Requisition Form

3850 Victoria St. N. MS-V310

Shoreview, MN 55126
Contact: Shauna Stephens
Tel: 763-514-8084 Fax: 763-514-8089

Customer: Selecciones Medicas S.A. de C.V. Shipment Method: X Air Truck

Address: Sinaloa #85 Col. Roma Freight Forwarder/Courier: Superior Freight Service Inc
C.P. 06700, Mexico D.F. Address: 2600 East 81 Street
Tel: (52) 55 50 80 15 00 Bloomington, MN 55425
Fax: (52) 55 50 80 15 48 Tel: (952) 854 5053
Contact Person: Fax: (952) 646 0893
Purchase Order#: Contact Person: Charlie Jakala

Incoterms: CPT CIF CIP X EXW Quality Certificate: X Sterilization Certificate:

Import License#: Cotecna/SGS inspection#:

Special Instructions: Ship to consignee: Fernandez Hinojosa y Cia S.C.

Soles 56 Col. Peñon de los Banos, C.P. 15520, Mexico D.F.

Cliente

QTY MODEL DESCRIPTION SSA HS CODE

Date:
sition Form

od: X Air Truck

er/Courier: Superior Freight Service Inc.
2600 East 81 Street
Bloomington, MN 55425
854 5053
646 0893
: Charlie Jakala

te: X Sterilization Certificate:

xico D.F.

UNIT PRICE AMOUNT

EA
PK
Orden de
Compra IMSS
11341 21 May 07
11341 ISSSTE
Orden de
Compra QTY Pres Modelo Descripcion
11341
20 Ea sd303 A A
20 Ea sd303 A A
20 Ea sd303 A A
20 Ea sd303 A A
20 Ea sd303 A A
20 Ea sd303 A A
20 Ea sd303 A A
20 Ea sd303 A A
20 Ea sd303 A A
20 Ea sd303 A A
20 Ea sd303 A A
20 Ea sd303 A A
20 Ea sd303 A A
20 Ea sd303 A A
11341
20 EA ss ss ss
20 EA ss ss ss
20 EA ss ss ss
20 EA ss ss ss
20 EA ss ss ss
20 EA ss ss ss
20 EA ss ss ss
20 EA ss ss ss
20 EA ss ss ss
20 EA ss ss ss
20 EA ss ss ss
20 EA ss ss ss
 Unit
SSA HS Code Price Amount

A A A
A A A
A A A
A A A
A A A
A A A
A A A
A A A
A A A
A A A
A A A
A A A
A A A
A A A

ss 150 $1,501.00
ss 150 $1,501.00
ss 150 $1,501.00
ss 150 $1,501.00
ss 150 $1,501.00
ss 150 $1,501.00
ss 150 $1,501.00
ss 150 $1,501.00
ss 150 $1,501.00
ss 150 $1,501.00
ss 150 $1,501.00
ss 150 $1,501.00