Your Name

Your Email Address

Facility Or Company Name

Phone Number

Fax Number

Manufacturer

Date Of Manufacture

Computer Model  

Model of the printer  

Software Level  

Can it do a whole body scan Yes No

Please list the scanning sites

What is the Length of the table

Are the test phantoms present Yes No

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