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