Your Name

Your Email Address

Facility Or Company Name

Phone Number

Fax Number

Manufacturer

Date Of Manufacture

Model

Number Of Monitors 1 2

Age And Size Of The Image Intensifier

Type Of Storage

Does The System Have Digital Subtraction

List The Diagnostic Packages

Are There Any Other Accessories

Who Is Servicing The System

On A Scale Of 1 To 10, Please Rate The Cosmetic Condition 1 2 3 4 5 6 7 8 9 10

When Is The System Available For Removal

When Do You Need An Offer By

Do Any Walls Have To be Removed To Get The System De-installed No Yes

Is There A Loading Dock At Your Facility Yes No

Asking Price

Any Additional Comments Or Accessories