Contact Name
*
Facility Name
*
Contact Phone
*
Email Address
*

Ship to Address
*


City
State
ZIP

Sales Rep*
Select Patsy LeBlanc Don Callahan Rich Bolthouse Scott Stapleton Gary Klein Chad Keiser Darrin Pelkey Mark Kocaba Mark Aguirre

Quote Number (If Available)
*
Sales Order Number (If Available)



1. When would you like your delivery to be made?
January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2007 2008 2009 2010 Time *

2. Is area zoned to have a large (35ft-45ft) truck on the street?
yes no

3. Is your driveway accessible to the delivery truck?
yes no

4. What is the measurement of the SMALLEST door the driver will encounter while delivering your equipment?
Height Width

5. Is this a ground floor delivery?
yes no

6. Please note any steps/stairs that are involved:
Steps/Stairs Straight Staircase Tight Turns

7. What is the narrowest width measurement of the staircase?


8. What other obstacles may be encountered?


9. Will equipment have to be taken through other rooms before it is placed in the final installation area?
yes no

10. If your order includes POWER display(s) please notate your facilities elevation.
(Elevation required for proper calibration)
Feet

( Please insure all the information is accurate before sending )
* Required Fields