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On-Line Quote Form
To request a quote, please fill in the information below.
The ** indicates information that must be provided to properly process your order.
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Exam Lighting Products
#1: Contact Information
Date:
Company Name:
Contact Name:
Title:
Street Address:
City:
County:
State or Prov.:
Zip/Postal Code:
Country:
.
Billing Address:
Telephone #:
Ext.
Fax #:
Email Address:
(Required to process request)
Ship to Zip Code:
#2:
Product Lines
Model 421
Gooseneck Light Series
Model:
Select
421
423
424
Quantity:
Options:
Hospital Grade Wiring
Guard
Model 426
Conventional Shade Series
Model:
Select
426
428
429
Quantity:
Options:
Hospital Grade Wiring
Guard
Model 425 OB/GYN Light
Model:
Select
425
Quantity:
Nightingale Halogen ExamLite Series
Floor Model:
Select
H421=$200.00
H424=$273.20
Flex Arm Model:
Select
H221=$171.50
H222=$176.75
H223=$182.00
If Flex Arm Model, please Specify Mount:
Select
L-Flange
C-Clamp
Plate Mount
Quantity:
Comments:
© Copyright 2007 by Adjustable Fixture Co., and
Web Centers of America, Inc.
