November 2010

Please complete this order form electronically by clicking on each field below, print and return by fax. Handwritten copies will not be accepted. All orders require Department Head approval and cost center# for processing. Due to limited inventory and volume orders for lab coats A-C may not be filled until Jan 2011.

LAB COAT REQUEST FORMMontefiore Central Laundry Facilities - Phone: 718-617-0440

Fax: 718-542-5893 (Attention Ron Allen)

Location: Moses___ Weiler____ North____ Other___________

Name of person placing request:______________________________ Phone: _________________________________

Check One: New___ Replacement____ New Hire____ Date of Request: _____________________________

Name of person wearing Labcoat:_____________________________ EZ ID: _________________________________

Title/Position:______________________________ Department/Division: _________________________________

Department Head Approval: Print Name: ____________________________ Signature: ____________________________

Email Address:____________________________________________ CC# _____________________________ (Person approving and picking up order)

DEPARTMENT HEAD DEPARTMENT HEAD

ITEM # DESCRIPTION SELECT LOGOIMPRINT

SIZE RANGE QTY SIZE

RESIDENTS, NURSES AND OTHER CLINICAL STAFF with job duties that require labcoats113694-0 (A) Staff Length Lab Coat, White, (F) MMC CHAM 4-28

110528-92 (A) Staff Length Lab Coat (M), White Regular Tall MMC CHAM 28-60

113694-0 (B) Staff Length Lab Coat, Green, (F) MMC CHAM 4-28

110528-92 (B) Staff Length Lab Coat (M), Green, Regular Tall MMC CHAM 28-60

ATTENDINGS and NURSE MANAGERS/DIRECTORS without dual appointment at Einstein (Personalized)113694-0 (B) Staff Length Lab Coat, White, (F) MMC CHAM 4-28

110528-92 (B) Staff Length Lab Coat (M), White Regular Tall MMC CHAM 28-60

ATTENDINGS with dual appointment at Einstein (Personalized)113694-0 (C) Staff Length Lab Coat, White, (F) MMC CHAM 4-28

110528-92 (C) Staff Length Lab Coat (M), White Regular Tall MMC CHAM 28-60

CHAIRS , CHIEFS and ATTENDINGS with dual appointment at Einstein (Personalized)113695-0 (D- Chiefs & Chairs Only) Knot Button Lab Coat (F), White MMC CHAM 4-28

110530-92 (D- Chiefs & Chairs Only) Knot Button Lab Coat (M) MMC CHAM 32-60

NAME

TITLE, DEPARTMENT Line 1

DEPARTMENT Line 2 (Optional)

For personalized orders: Data entered will be embroidered exactly as shown.

PLEASE NOTE: A Maximum of 4 lab coats are available per person annually. No Exceptions.

MCL OFFICE USE ONLY

Acct # 45187180001

Log Req ____________________

Log Issue ____________________

Log Received ____________________

Cancel Request ____________________

5600 West 73rd Street – Chicago, IL 60638 Call 1-800-UNIFORM

www.cintas.com

SEE GUIDELINES ON 2ND PAGE

(Do not list Programs or Centers)

NURSE MANAGERS/DIRECTORS and ATTENDINGSwithout dual appointment at Einstein

Logo with personalization up to 3 lines max

Fabric: 65/35 poly/cotton twill

RESIDENTS, NURSES and OTHER CLINICAL STAFFwith job duties that require labcoats

Logo Only - no personalization

Fabric: 65/35 poly/cotton twill, Green for laboratory staff

FirstName LastName, MDTitle, Department

FirstName LastName, MDTitle, Department

FirstName LastName, MDTitle, Department

FirstName LastName, MDTitle, Department

CHAIRS, CHIEFS and ATTENDINGS with dual appointment at Einstein

Co-Branding with personalization up to 3 lines max

Fabric: 65/35 poly/cotton twill for Attendings (C) 100% cotton for Chiefs and Chairs Only (D)

(A) MMC

(A) CHAM

(B) MMC

(B) CHAM

(C/D) MMC

(C/D) CHAM

MONTEFIORE GUIDELINES FOR LABCOAT ORDERS - 11/2010

NURSE MANAGERS/DIRECTORS and ATTENDINGSwithout dual appointment at Einstein

Logo with personalization up to 3 lines max

Fabric: 65/35 poly/cotton twill

RESIDENTS, NURSES and OTHER CLINICAL STAFFwith job duties that require labcoats

Logo Only - no personalization

Fabric: 65/35 poly/cotton twill, Green for laboratory staff

FirstName LastName, MDTitle, Department

FirstName LastName, MDTitle, Department

FirstName LastName, MDTitle, Department

FirstName LastName, MDTitle, Department

CHAIRS, CHIEFS and ATTENDINGS with dual appointment at Einstein

Co-Branding with personalization up to 3 lines max

Fabric: 65/35 poly/cotton twill for Attendings (C) 100% cotton for Chiefs and Chairs Only (D)

(A) MMC

(A) CHAM

(B) MMC

(B) CHAM

(C/D) MMC

(C/D) CHAM

MONTEFIORE GUIDELINES FOR LABCOAT ORDERS - 11/2010

NURSE MANAGERS/DIRECTORS and ATTENDINGSwithout dual appointment at Einstein

Logo with personalization up to 3 lines max

Fabric: 65/35 poly/cotton twill

RESIDENTS, NURSES and OTHER CLINICAL STAFFwith job duties that require labcoats

Logo Only - no personalization

Fabric: 65/35 poly/cotton twill, Green for laboratory staff

FirstName LastName, MDTitle, Department

FirstName LastName, MDTitle, Department

FirstName LastName, MDTitle, Department

FirstName LastName, MDTitle, Department

CHAIRS, CHIEFS and ATTENDINGS with dual appointment at Einstein

Co-Branding with personalization up to 3 lines max

Fabric: 65/35 poly/cotton twill for Attendings (C) 100% cotton for Chiefs and Chairs Only (D)

(A) MMC

(A) CHAM

(B) MMC

(B) CHAM

(C/D) MMC

(C/D) CHAM

MONTEFIORE GUIDELINES FOR LABCOAT ORDERS - 11/2010

NURSE MANAGERS/DIRECTORS and ATTENDINGSwithout dual appointment at Einstein

Logo with personalization up to 3 lines max

Fabric: 65/35 poly/cotton twill

RESIDENTS, NURSES and OTHER CLINICAL STAFFwith job duties that require labcoats

Logo Only - no personalization

Fabric: 65/35 poly/cotton twill, Green for laboratory staff

FirstName LastName, MDTitle, Department

FirstName LastName, MDTitle, Department

FirstName LastName, MDTitle, Department

FirstName LastName, MDTitle, Department

CHAIRS, CHIEFS and ATTENDINGS with dual appointment at Einstein

Co-Branding with personalization up to 3 lines max

Fabric: 65/35 poly/cotton twill for Attendings (C) 100% cotton for Chiefs and Chairs Only (D)

(A) MMC

(A) CHAM

(B) MMC

(B) CHAM

(C/D) MMC

(C/D) CHAM

MONTEFIORE GUIDELINES FOR LABCOAT ORDERS - 11/2010

NURSE MANAGERS/DIRECTORS and ATTENDINGSwithout dual appointment at Einstein

Logo with personalization up to 3 lines max

Fabric: 65/35 poly/cotton twill

RESIDENTS, NURSES and OTHER CLINICAL STAFFwith job duties that require labcoats

Logo Only - no personalization

Fabric: 65/35 poly/cotton twill, Green for laboratory staff

FirstName LastName, MDTitle, Department

FirstName LastName, MDTitle, Department

FirstName LastName, MDTitle, Department

FirstName LastName, MDTitle, Department

CHAIRS, CHIEFS and ATTENDINGS with dual appointment at Einstein

Co-Branding with personalization up to 3 lines max

Fabric: 65/35 poly/cotton twill for Attendings (C) 100% cotton for Chiefs and Chairs Only (D)

(A) MMC

(A) CHAM

(B) MMC

(B) CHAM

(C/D) MMC

(C/D) CHAM

MONTEFIORE GUIDELINES FOR LABCOAT ORDERS - 11/2010NURSE MANAGERS/DIRECTORS and ATTENDINGSwithout dual appointment at Einstein

Logo with personalization up to 3 lines max

Fabric: 65/35 poly/cotton twill

RESIDENTS, NURSES and OTHER CLINICAL STAFFwith job duties that require labcoats

Logo Only - no personalization

Fabric: 65/35 poly/cotton twill, Green for laboratory staff

FirstName LastName, MDTitle, Department

FirstName LastName, MDTitle, Department

FirstName LastName, MDTitle, Department

FirstName LastName, MDTitle, Department

CHAIRS, CHIEFS and ATTENDINGS with dual appointment at Einstein

Co-Branding with personalization up to 3 lines max

Fabric: 65/35 poly/cotton twill for Attendings (C) 100% cotton for Chiefs and Chairs Only (D)

(A) MMC

(A) CHAM

(B) MMC

(B) CHAM

(C/D) MMC

(C/D) CHAM

MONTEFIORE GUIDELINES FOR LABCOAT ORDERS - 11/2010

NURSE MANAGERS/DIRECTORS and ATTENDINGSwithout dual appointment at Einstein

Logo with personalization up to 3 lines max

Fabric: 65/35 poly/cotton twill

RESIDENTS, NURSES and OTHER CLINICAL STAFFwith job duties that require labcoats

Logo Only - no personalization

Fabric: 65/35 poly/cotton twill, Green for laboratory staff

FirstName LastName, MDTitle, Department

FirstName LastName, MDTitle, Department

FirstName LastName, MDTitle, Department

FirstName LastName, MDTitle, Department

CHAIRS, CHIEFS and ATTENDINGS with dual appointment at Einstein

Co-Branding with personalization up to 3 lines max

Fabric: 65/35 poly/cotton twill for Attendings (C) 100% cotton for Chiefs and Chairs Only (D)

(A) MMC

(A) CHAM

(B) MMC

(B) CHAM

(C/D) MMC

(C/D) CHAM

MONTEFIORE GUIDELINES FOR LABCOAT ORDERS - 11/2010