Portable Form:

Manufacturer Model Production Year
S/N SiteID Available Date
SW Rev Current Settings

Originally Purchased  by:

Collimator Model:

Tube Type Tube install date: 
Housing Focal Spots 

Digital System
Flat Panel Detector


Type: Last Replaced:



System is:

System Details

System is in good working condition and not in need of repair?
  with:
Location in facility (room number)  on floor 
Loading dock is available? 
System being replaced by: 

Site Info

Company/Entity:
* Name/Rep: *
* Email: *
Phone:
Deal Status:
Address:
Address (cont.)
City:
State/Province:
Country:
Zip Code: