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Email: *
Company / Facility: *
Equipment Model: *
Year: *	Manufacturer: *
Hertz:	50Hz      60Hz
Site ID:
System Serial Number:
Gantry Count:
Computer:
Tube Count:
Tube Serial Number:
Storage Device:	Select Magnetic Tape Optical Disk Other
Consoles:	Operator Diagnostic Independent Workstation Other
Imager:	Select 3M 831 3M 952 3M 959 Kodak 1120 Kodak 2180 Kodak Dryview 8100 Kodak Dryview 8700 Other
Generator:	Select 24kW 32kW 36kW 42kW 48kW Other
Software Revision, Other Features, Other Hardware:
Availability Date:
Installed        Deinstalled
Where is system?	Select Hospital Clinic Warehouse CIF Other
Loading dock at the facility?	Yes No
Includes:	Manuals Phantoms Cabling Base Plate
Quote for:	Market Valuation       Sale
Trailer Information:
Manufacturer:
Year of Manufacture:
VIN Number:
Length:
Refurbished: If yes, date:	Select Yes No
Air Conditioning:	Select Yes No
Generator: If yes, Make/Model: If yes, Wattage:	Select Yes No kW