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Scandmed Customer and Returns Form

Please fill out and submit the form below. We will contact you shortly.
Requirements - PO#, Authorizing $750 or less expedites service. We bill only as required.

Financial Information
Company Name:
Tax ID:
DUNS:
Payment Terms:
Purchase Order Required? Yes No
Description
PN:
IE 400-40:
Describe problem:
Contacts (Billing)
First Name:
Last Name:
Title:
Street Address:
City:
State:
Zip:
Phone:
Fax:
Email:
Remarks:
Contacts (Shipping) Check if same as billing
First Name:
Last Name:
Title:
Street Address:
City:
State:
Zip:
Phone:
Fax:
Email:
Remarks:
Shipping Mode:
UPS FedEx Customer drops off/picks up
($12 handling fee to ship)
Other shipping instruction (describe below):


©2006 Century Labs II Corporation

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