Mindways Order Form

ORDER

To place an order, complete the following information fields. All applicapable fileds must be completed before the order will be processed. If you are a scanner manufacturer or distributor, you must complete the End User information. Upon receipt of your order you will be sent an order confirmation.

Purchase Order #

Order Reference #

Date Required

BILLING INFORMATION

Name

Address

City

State/Province

ZIP/Postal Code

Country

Attention

Telephone

Fax

SHIPPING INFORMATION

Same as billing

Address

City

State/Province

ZIP/Postal Code

Country

Attention

Telephone

Fax

SCANNER INFORMATION

Manufacturer

Model

DICOM

END USER INFORMATION

Please complete the following information if the end user is different than the bill to/ship to information.

Hospital/Clinic

Address

City

State

ZIP/Postal Code

Country

Contact Name

Telephone

Fax

ITEMS

Qty	Item	Cost