Special Order Form

I understand the following products from Hormel Health Labs are not yet currently stocked, but are available by special order. I am requesting that this product be available as a stock item at my primary distributor.

HHL ITEM CODE	PACK	PRODUCT DESCRIPTION	CS USAGE/WK
45448	100/4g	Thick & Easy® Thickener for Supplemental Drinks
67010	24/2.5oz	Thick & Easy® Pureed Shaped Breakfast Omelet
67011	24/2.5oz	Thick & Easy® Pureed Shaped Breakfast Sausage Links
67012	24/2.5oz	Thick & Easy® Pureed Shaped Breakfast Waffle

I understand this is not an order and I will be notified to place my order when these products are available for purchase.

My primary distributor:
Location:

		Date:
First Name:		Last Name:
Title:
Facility Name:
Address:

City:		State:
Zip:
e-mail:		Phone: