Your Name

Your Email Address

Facility Or Company Name

Phone Number

Fax Number

Manufacturer

Date Of Manufacture

Generator Model  

Is it Single Or Three Phase Three Phase Single Phase

Is It High Frequency No Yes  

Maximum MAs

Does It Have Phototiming Yes No  

Table Model

Does Table Elevate No Yes

Is It 2 Way Or 4 Way 2 Way 4 Way

Type Of Tube Stand Overhead Integrated Floor To Wall

Model and Age Of The X Ray Tube  

Does The System Have A Tomo Attachment

Is There a Wall Bucky Yes No

Is There a Processor Yes No Model

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