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Hospital Name and City:
______________________________________________
Customer #: ______________________
Hospital P.O. # ___________________
Date: _________________ Taken
by: __________________________________
Sales Rep Name:
______________________ Quantity: ______ S: ___________
Catalogue #: __________________
Packslip #: __________________________
DRAWINGS
1. Maximum Length
_________________________
2. Maximum Width
__________________________
3. Width __________________________________
4. Length _________________________________
5. Length _________________________________
6. Length _________________________________
7. Length _________________________________
8. Length _________________________________
| |
|
|
Material: __ Nylon __ Leatherette |
Colour:
___________________________ |
| |
|
| Velcro on Bottom: |
__ Yes __ No |
Foam Thickness: __
1" __ 1 1/2" __ 2" |
| |
__ Hook __
Loop |
Adhesive Velcro for
Table: __ Yes __ No |
| |
|
Special Instructions:
REF#:
______________________________________________________________
____________________________________________________________________ |
