PRODUCT ORDER FORM
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PRODUCT ORDER FORM NORTH AMERICA | ACCENT CUSTOMER # PROSTHETIST INFORMATION BILLING SHIPPING (LEAVE BLANK IF SAME AS BILLING) DATE REQUIRED *ORDERS SHIP UPS GROUND ON THE FOLLOWING DAY UNLESS SPECIFIED. PATIENT INFORMATION PROSTHETIST NAME PATIENT ID / NAME REFERENCE U.S. Shoe size chart cm ADJUSTABLE HEEL PART ID SHELL COLOR Integrated Pyramid BUTTON PLACEMENT Dynamic Pylon + Receiver DF Additional Accessories: ¨ Shelltread Ask about Skinergy cosmetic covers! Dynamic Pylon + Adapter DM Dynamic Pylon + 4-hole FIRMNESS CATEGORY College Park suggests the Wide option for male patients. LOW IMPACT MODERATE IMPACT EMAIL COMPLETED ORDER FORM TO: orders@college-park.com 27955 College Park Dr, Warren, MI 48088, USA TOLL FREE 800.728.7950 FAX 586.294.0067 ON THE WEB college-park.com

PRODUCT ORDER FORM NORTH AMERICA | BREEZE CUSTOMER # PROSTHETIST INFORMATION BILLING SHIPPING (LEAVE BLANK IF SAME AS BILLING) DATE REQUIRED *ORDERS SHIP UPS GROUND ON THE FOLLOWING DAY UNLESS SPECIFIED. PATIENT INFORMATION PROSTHETIST NAME PATIENT ID / NAME REFERENCE U.S. Shoe size chart cm SHELL COLOR Additional Accessories: ¨ Shelltread FIRMNESS CATEGORY EMAIL COMPLETED ORDER FORM TO: orders@college-park.com 27955 College Park Dr, Warren, MI 48088, USA TOLL FREE 800.728.7950 FAX 586.294.0067 ON THE WEB college-park.com

PRODUCT ORDER FORM NORTH AMERICA | CELSUS CUSTOMER # PROSTHETIST INFORMATION BILLING SHIPPING (LEAVE BLANK IF SAME AS BILLING) DATE REQUIRED *ORDERS SHIP UPS GROUND ON THE FOLLOWING DAY UNLESS SPECIFIED. PATIENT INFORMATION PROSTHETIST NAME PATIENT ID / NAME REFERENCE U.S. Shoe size chart cm SHELL COLOR FIRMNESS CATEGORY Additional Accessories: ¨ Shelltread EMAIL COMPLETED ORDER FORM TO: orders@college-park.com 27955 College Park Dr, Warren, MI 48088, USA TOLL FREE 800.728.7950 FAX 586.294.0067 ON THE WEB college-park.com

PRODUCT ORDER FORM PROSTHETIST INFORMATION BILLING SHIPPING (LEAVE BLANK IF SAME AS BILLING) DATE REQUIRED *ORDERS SHIP UPS GROUND ON THE FOLLOWING DAY UNLESS SPECIFIED. PATIENT INFORMATION PROSTHETIST NAME PATIENT ID / NAME REFERENCE U.S. Shoe size chart cm SHELL COLOR SIZE CM HIGH IMPACT LOW-MODERATE IMPACT Additional Accessories: FIRMNESS CATEGORY EMAIL COMPLETED ORDER FORM TO: orders@college-park.com 27955 College Park Dr, Warren, MI 48088, USA TOLL FREE 800.728.7950 FAX 586.294.0067 ON THE WEB college-park.com

PRODUCT ORDER FORM NORTH AMERICA | ODYSSEY K2 CUSTOMER # PROSTHETIST INFORMATION BILLING SHIPPING (LEAVE BLANK IF SAME AS BILLING) DATE REQUIRED *ORDERS SHIP UPS GROUND ON THE FOLLOWING DAY UNLESS SPECIFIED. PATIENT INFORMATION PROSTHETIST NAME PATIENT ID / NAME REFERENCE U.S. Shoe size chart cm SHELL COLOR Additional Accessories: ¨ Shelltread FIRMNESS CATEGORY EMAIL COMPLETED ORDER FORM TO: orders@college-park.com 27955 College Park Dr, Warren, MI 48088, USA TOLL FREE 800.728.7950 FAX 586.294.0067 ON THE WEB college-park.com

PRODUCT ORDER FORM NORTH AMERICA | ODYSSEY K3 CUSTOMER # PROSTHETIST INFORMATION BILLING SHIPPING (LEAVE BLANK IF SAME AS BILLING) DATE REQUIRED *ORDERS SHIP UPS GROUND ON THE FOLLOWING DAY UNLESS SPECIFIED. PATIENT INFORMATION PROSTHETIST NAME PATIENT ID / NAME REFERENCE U.S. Shoe size chart cm SHELL COLOR Additional Accessories: ¨ Shelltread FIRMNESS CATEGORY LOW IMPACT MODERATE IMPACT EMAIL COMPLETED ORDER FORM TO: orders@college-park.com 27955 College Park Dr, Warren, MI 48088, USA TOLL FREE 800.728.7950 FAX 586.294.0067 ON THE WEB college-park.com

PRODUCT ORDER FORM NORTH AMERICA | SIDEKICKS CUSTOMER # PROSTHETIST INFORMATION BILLING SHIPPING (LEAVE BLANK IF SAME AS BILLING) DATE REQUIRED *ORDERS SHIP UPS GROUND ON THE FOLLOWING DAY UNLESS SPECIFIED. PATIENT INFORMATION PROSTHETIST NAME PATIENT ID / NAME REFERENCE FIRMNESS CATEGORY EMAIL COMPLETED ORDER FORM TO: orders@college-park.com 27955 College Park Dr, Warren, MI 48088, USA TOLL FREE 800.728.7950 FAX 586.294.0067 ON THE WEB college-park.com

PRODUCT ORDER FORM NORTH AMERICA | SOLEUS CUSTOMER # PROSTHETIST INFORMATION BILLING SHIPPING (LEAVE BLANK IF SAME AS BILLING) DATE REQUIRED *ORDERS SHIP UPS GROUND ON THE FOLLOWING DAY UNLESS SPECIFIED. PATIENT INFORMATION PROSTHETIST NAME PATIENT ID / NAME REFERENCE U.S. Shoe size chart cm Perfect Pink Midnight Black HOUSING COLOR College Park suggests the Wide option for male patients. FIRMNESS CATEGORY Additional Accessories: SHELL COLOR Shelltread Rotatable Adapter Rotatable Receiver Standard Adapter - Titanium Standard Receiver - Titanium Standard Adapter - Stainless Steel Standard...

PRODUCT ORDER FORM NORTH AMERICA | SOLEUS CUSTOMER # PROSTHETIST INFORMATION BILLING SHIPPING (LEAVE BLANK IF SAME AS BILLING) DATE REQUIRED *ORDERS SHIP UPS GROUND ON THE FOLLOWING DAY UNLESS SPECIFIED. PATIENT INFORMATION PROSTHETIST NAME SOLEUS FIRMNESS CATEGORIES WEIGHT LBS CUSTOM ENGRAVINGS Check one box under design. Allow two extra days for processing. No additonal charge. Soleus only. NO ENGRAVING SUPER STARS LIGHTNING ON YOUR FEET EMAIL COMPLETED ORDER FORM TO: orders@college-park.com 27955 College Park Dr, Warren, MI 48088, USA TOLL FREE 800.728.7950 FAX 586.294.0067 ON THE WEB...

PRODUCT ORDER FORM NORTH AMERICA | TEMPO CUSTOMER # PROSTHETIST INFORMATION BILLING SHIPPING (LEAVE BLANK IF SAME AS BILLING) DATE REQUIRED *ORDERS SHIP UPS GROUND ON THE FOLLOWING DAY UNLESS SPECIFIED. PATIENT INFORMATION PROSTHETIST NAME PATIENT ID / NAME REFERENCE U.S. Shoe size chart cm FIRMNESS CATEGORY Additional Accessories: ¨ Shelltread SHELL COLOR EMAIL COMPLETED ORDER FORM TO: orders@college-park.com 27955 College Park Dr, Warren, MI 48088, USA TOLL FREE 800.728.7950 FAX 586.294.0067 ON THE WEB college-park.com

PRODUCT ORDER FORM NORTH AMERICA | TRIBUTE CUSTOMER # PROSTHETIST INFORMATION BILLING SHIPPING (LEAVE BLANK IF SAME AS BILLING) DATE REQUIRED *ORDERS SHIP UPS GROUND ON THE FOLLOWING DAY UNLESS SPECIFIED. PATIENT INFORMATION PROSTHETIST NAME PATIENT ID / NAME REFERENCE U.S. Shoe size chart cm SHELL COLOR Regular Toe Leave Blank FIRMNESS CATEGORY Additional Accessories: ¨ Shelltread *Wide not available in Sandal Toe. Leave field blank if ordering Sandal Toe. College Park suggests the Wide option for male patients. LOW IMPACT MODERATE IMPACT EMAIL COMPLETED ORDER FORM TO:...