1120: External DC Power Charger

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Order Information

Purchase Order Number

GPO / IDN Affiliation

The GPOs / IDNs listed below are the ones we currently accept. If you do not see yours or are unsure of your affiliation, select "None / Unknown" and we will verify with you once we process your order.

Authorized Buyer Name

First Name

Last Name

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(###)

###

####

Requested Delivery Date

***If expedited shipping is needed, please confirm in the special instructions box the time and date.

MM

DD

YYYY

Ship VIA

If "No preference" is selected, items will ship FedEx Ground.

FedEx

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Freight Account Number

SHIPPING

Hospital Name

Shipping Address

Address 1

Address 2

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Country

Ship To Attention:

BILLING

Checkbox

Billing Address is the same as Shipping Address

Billing Address

Address 1

Address 2

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Special Instructions

Please list any special instructions below (ex. delivery instructions, expedited shipping, etc.)