| Date: / / / |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Purchase Order #: |
|
|
|
|
Estimate |
|
Order |
|
|
|
|
|
|
|
|
|
| |
Bill to Address |
|
|
|
|
Ship to Address |
|
| |
|
|
|
|
|
|
|
|
| |
|
|
|
|
|
|
|
|
| |
|
|
|
|
|
|
|
|
| Contact |
|
|
|
Contact |
|
|
|
|
| |
|
|
|
|
|
|
|
|
| |
|
|
|
|
|
|
|
|
| |
|
|
|
|
|
|
|
|
| |
|
|
|
|
|
|
|
|
| |
|
|
|
|
|
|
|
|
| |
|
|
|
|
|
|
|
|
| |
|
|
|
|
|
|
|
|
| Phone: |
|
Fax: |
|
Phone: |
|
|
Fax: |
|
| |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| |
Transportation Information |
|
|
|
Sale Terms |
|
| Ship Date: |
Ship |
Via: |
F.O.B. |
|
|
Net: |
C.O.D. |
C.I.A. |
| |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| |
Lift Platform Size |
|
Lift Price |
|
|
Vehicle Information |
|
| Ambulance Lift 24"X44 - 450cap |
Isolet |
|
$ |
|
Vin #: |
|
|
| Ambulance Lift 24"X64" - 750cap |
30 cot-ballon pump |
$ |
|
Make: |
|
|
| Ambulance Lift 24"X76" - 750cap |
Striker MX Pro |
$ |
|
|
|
|
| Ambulance Lift 24"X88" - 750cap |
35 cot |
|
$ |
|
Model: |
|
|
| Ambulance Lift Cot & Datascope 108" Length |
$ |
|
Year: |
|
|
| Ambulance Lift 30"X80" 1000cap Bariatric Cot |
$ |
|
|
|
|
| Bariatric Ramp & Winch System Complete |
$ |
|
Lift Serial #: |
|
|
|
|
|
|
|
|
|
|
|
| Lift Specs: |
Ambulance Dimesnion Check List |
|
|
|
|
|
| Please Complete Dimensions Completely to Order Proper Lift |
|
|
Dimensions |
| |
|
|
|
|
a. |
|
Dept-Cross Frame to Skirt |
| Ambulance Manufacturer: ______________________________ |
b. |
|
Width-Narrowest Area |
| |
|
|
|
|
c. |
|
Floor height to Ground |
| Ambulance Model: ____________________ |
Year: _______________ |
d. |
|
Ground to Bottom of Frame |
| |
|
|
|
|
e. |
|
Floor to Bottom of Frame |
| Chassie Manufacturer: |
Ford E 350 |
Ford E 450 |
f. |
|
Depth of Bumper |
| Ford F 350 Ford F 450 |
Chev 3500 |
Chev 4500 |
Freightliner |
Navistar |
g. |
|
Clear Space Under Frame |
| Ford F 450 |
Chev 5500 |
|
International |
h. |
|
Floor to Top of Step |
 |
| Special Instructions: |
|
|
|
|
Sub-Total: |
$ |
|
| Pump Compartment: Forward of Axel - Rear of Axel |
|
Sales Tax: |
$ |
|
| Larger Capacity 1000 pounds |
|
|
|
Other: |
$ |
|
| Bariatric Stryker Cot Size Platform |
|
|
|
Freight: |
$ |
|
| |
|
|
|
