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Digital QC Phantom Order Form

Item	Qty	Price/Unit	Total
Digital Imaging QC Phantom & Binder		$500.00	$0.00
Digital QC Program Setup & Training (Optional)		$300.00	$0.00
Sales Tax (Texas)		8.25%	$0.00
Grand Total			$0.00

Date

Ordered By

Ship/Deliver to Co.

Ship to Address

Billing Company Name

Billing Address

Phone

PO #

Email

Attention

City, State, Zip

Attention

City, State, Zip

Fax

Phantom and Binder Package Prices/Discounts: $475 for 1-4, $325 for 5-9 and $300 for 10+.

Grand Total does not include out of town travel (outside of DFW metroplex).
Payment may be requested in advance of shipping or delivery.
It is the responsibility of the client to return a sales tax exempt form for tax to be excluded.