Imaging Solutions, Inc.

If you have to yet to speak with an ISI Healthcare representative regarding availability please call (701) 297-0305 prior to submitting this form.

		All fields in Blue must be completed.
Type of Rental :
Term Start Date :
Term End Date :

		Billing Information Enter none in the fields that do not apply.
Name :
Address (Line 1) :
Address (Line 2) :
City :
State :
Zip :
Phone No. :
Fax :
Contact :
Title :
Email :
Customer Type :
Rental Reason :

		Shipping Information Check here if the same with Billing Information. Enter none in the fields that do not apply.
Name :
Address (Line 1) :
Address (Line 2) :
City :
State :
Zip :
Phone No. :
Fax :
Contact :
Title :
Email :

		Payment Method Enter none if not applicable.
Who will be paying this rental?
Purchase Order No. :
OEM No. :
Notes :

		Sales Information For use by equipment vendors only. Enter none in the fields that do not apply.
Sales Rep :
Sales Rep ID :
Phone No. :
Email Address :
Voice Mail :
Cell :

		OEM Information Enter none in the fields that do not apply.
Field Engineer :
Phone No. :
Area Service Manager :
Phone No. :
Modality Specialist :
SSO No. :
OEM Notes :