Your Name

Your E mail Address

Facility Or Company Name

Phone Number

Fax Number

Trailer Information

Trailer Manufacturer

Date Of Manufacture

Length Of Trailer  

Mileage

Number Of Popouts

Generator Size

Type Of A/C Unit

Condition Of Hydraulics  

On a Scale Of 1 To 10 Rate The Cosmetic Condition 1 2 3 4 5 6 7 8 9 10

Is the System On A Route Or Parked

CT Scanner Information

Manufacturer

Date Of Manufacture

Model

Does The System Do  Helical Scanning Yes No

If The System Is Helical, How Fast Can it do a Full Rotation 1 Second 1.5 Second Sub Second   

Number Of Slices or Scan Seconds On Gantry Slices Scan Seconds

Number Of Slices Or Scan Seconds On Tube Slices Scan Seconds

Model and Heat Unit Rating Of The Tube

What is the Size Of The Generator

Number Of Consoles 1 2 3

Is There a 3D Workstation Yes No What Model

Type Of Computer

Software Level

Diagnostic Packages i.e.  Angio, Dental

Type Of Storage Device

Is There A Imager Included Yes No   Model

When Is The System Available For Removal

When do You Need An Offer By

Who Is Servicing The System

On A Scale Of 1 To 10, Please Rate The Cosmetic Condition 1 2 3 4 5 6 7 8 9 10

Do Any Walls Have To be Removed To Get The System De-installed No Yes

Is There A Loading Dock At Your Facility Yes No

Asking Price

Any Additional Comments