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Your email address

Type of Request

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Type of DIR Request

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Medline Branch

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Medline Branch

Reason for Cancel(optional)

Attaching spreadsheet for multiple requests?(optional)

1 Vendor per attachment - Please include PO Number, Material, Branch, and Quantity

Attaching spreadsheet for multiple requests?(optional)

1 Vendor per attachment - Please include PO Number, Material, and Branch

Attaching spreadsheet for multiple requests?(optional)

1 Vendor per attachment - Please include PO Number, Material, Branch, and Quantity

Attaching spreadsheet for multiple requests?(optional)

1 Vendor per attachment - Please include PO Number, Material, Branch, and Quantity

Customer Sales Order

Vendor PO Number(optional)

Vendor PO begins with 451...

Medline Material

Please use internal Medline item number

Quantity(optional)

Please enter quantity needed to cancel/reduce by

Customer Account Number

Please enter in Customer Account Number (if cancelling DED, provide account # DED is under)

Customer Name(optional)

Subject

Description

Please enter the details of your request. A member of our support staff will respond as soon as possible.

Attachments(optional)

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