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 2010 2011 2012 2013 Time *

2. Delivery restrictions (check all that apply):
Mon-Fri Only Sat Only After Hours Only

3. Is this a brand new facility?
yes no

4. If yes, is it still under construction?
yes no

5. Do you have a grand opening date?
yes (If yes specify date) 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 2010 2011 2012 2013 2014 no

6. Has new carpet or flooring been installed in the delivery area?
yes no

7. Is area zoned to have a large (35ft-75ft) truck on the street?
yes no

8. Do you have a receiving dock?
yes no

9. If NO, how close will truck be able to pull up to entrance of building for delivery?
Feet

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

11. Is this a ground floor delivery?
yes no

12. Is a freight elevator available to use?
yes no

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

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


15. What other obstacles may be encountered?


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

17. 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