Adjustable Fixture Co

On-Line Form

To request a Sample(s), 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.
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Exam Lighting Products

NO-RISK SAMPLE:
Try a lamp for 30 days and compare it to any other lamp you may be considering. You will quickly discover the Nightingale advantages: special features, heavy-duty construction and low life-cycle costs. Please fill out the following form or call us at the above number and we will rush you a sample within a week. The lamp may be returned at any time during that period at no cost to you. After 30 days, return it or send us your payment. It's that easy to try the best from Nightingale® and Ajusco®.

#1: Contact Information
P.O. #		Date:
Account #:
Contact Name:		Contact Phone:
BILL TO :
Company/Name:	**	Address:	**
City:	**	State/Prov.:	**
Zip/Postal:		Country:
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:
Options:	Hospital Grade Wiring=$18.80	Guard=$6.55
	Base Price Total Cost:

Model 426 Conventional Shade Series
Model:
Options:	Hospital Grade Wiring=$18.80	Guard=$6.55
	Base Price Total Cost:
Model 425 OB/GYN Light
Model:
	Base Price Total Cost:

Model 470 Tru-Light Series
Model:	Shade Color:
Options:	Hospital Grade Wiring=$18.80
	Base Price Total Cost:

Nightingale Halogen ExamLite Series
Floor Model:	Flex Arm Model:
If Flex Arm Model, please Specify Mount:
	Base Price Total Cost:
#3: Charge Card Information
MC Visa AM.EXPRESS Name on card: Card #: Exp. Date: