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Multi-Housing
On-Line Forms
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Contact Us
On-Line Order Form
To order, please fill in the information below.
The ** indicates information that must be provided to properly process your order.
If you have any questions, please do not
hesitate to inquire through
email
or call us direct at the above number.
Remember do NOT use the
ENTER KEY
on this page. (Tab Key or Mouse only)
Exam Lighting Products
#1: Contact Information
P.O. #
Date:
Account #:
Quote #:
Contact Name:
Contact Phone:
BILL TO :
Company/Name
:
**
Address:
**
City:
**
State/Prov.:
**
Zip/Postal:
Fax # :
Phone:
**
Email:
**
SHIP TO:
(if different)
Company/Name
:
Address:
City:
State/Prov.:
Zip/Postal:
Country:
Phone:
Email:
#2:
Product Lines
Model 421
Gooseneck Light Series
Model:
Select
421=$153.80
423=$166.50
424=$238.55
Options:
Hospital Grade Wiring=$21.80
Guard
=$7.65
Quantity:
Base Price Total Cost:
Model 426 Conventional Shade Series
Model:
Select
426=$125.95
428=$138.70
429=$210.70
Options:
Hospital Grade Wiring=$21.80
Guard
=$7.65
Quantity:
Base Price Total Cost:
Model 425 OB/GYN Light
Model:
Select
425=$241.95
Quantity:
Base Price Total Cost:
Nightingale Halogen ExamLite Series
Floor Model:
Select
H421=$220.50
H424=$305.25
Flex Arm Model:
Select
H221=$189.15
H222=$194.90
H223=$200.70
If Flex Arm Model, please Specify Mount:
Select
L-Flange
C-Clamp
Plate Mount
Quantity:
Base Price Total Cost:
#3:
Payment Information
Payment in $U.S. Dollars.
Note:
Sales tax will be charged to Wisconsin Buyer without a tax exempt form on fill at our corporate offices.
Open account, with approved credit!
Cash in Advance
MC
Visa
AM.EXPRESS Name on card:
Card #:
Please call with card Number
#4:
Shipping Information
Please send products via:
UPS- Reg. Ground
Fedex(see below)
Truck
Other(see below)
Your UPS #:
Your RPS #:
If other please state:
Additional Information to assist us in filling your order:
© Copyright 2007 by Adjustable Fixture Co., and
Web Centers of America, Inc.
