Mini C Arm for Sale, Lease, or Rent

Facility Information (Please complete all applicable fields)

Request Type(Required)

Request Type*

New

Change

Legal Company Name(Required)

Company Name & Address (doing business as)

Company Name(Required)

Company Address(Required)

Billing Name & Address (if different from legal name)

Billing Name

Billing Address

Type of Business & Purchase

Business Type(Required)

Business Type*

Sole Proprietor

Partnership

Corporation

Non-Profit

Government

Other

Business Type - Other(Required)

Employer Identification Number(Required)

Tax ID(Required)

Shipping Information

Ship To Location

Shipping Name(Required)

Shipping Address(Required)

FedEx Account Number

Do they have a loading dock?(Required)

Do they have a loading dock?*

Yes

Will a lift gate be necessary?(Required)

Will a lift gate be necessary?*

Yes

Any restrictions in the parking lot for a large trailer?(Required)

Any restrictions in the parking lot for a large trailer?*

Yes

Are there any elevators?(Required)

Are there any elevators?*

Yes

New Customer Form

Facility Information (Please complete all applicable fields)

Company Name & Address (doing business as)

Billing Name & Address (if different from legal name)

Type of Business & Purchase

Capital Equipment

Service

AP Contact Information

Radiology Equipment (Mini C-Arm) Contact

Materials Manager Contact

Biomedical Engineer Manager Contact

Shipping Information

Ship To Location

Approval Certification

I certify that the above information is correct