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EVAC+CHAIR® North America LLC

3000 Marcus Avenue, Suite 3E6 Lake Success, NY 11042 Tel: 516-502-4240 Fax: 516-327-8220 Internet: www.evac-chair.com E-mail: sales@evac-chair.com Our Federal ID: 26-1154735 Order Date: Purchase Order Number: Contact Name: Telephone Number: E-Mail Address for Confirmation: BILL TO: Organization: Address: City, State, Zip Code: Attention: SHIP TO: Organization: Address: City, State, Zip Code: Attention: EVACUTION CHAIRS EVAC+CHAIR® 300H (MK-3) EVAC+CHAIR ®600H IBEX® 700H AIR+CHAIR® Transit Chair

QTY ORDERED ____ ____@ __________@ __________@ __________@

UNIT PRICE $__________ $__________ $__________ $__________

EXT. PRICE $__________ $__________ $__________ $__________

Replacement Vinyl Dust Cover ____ ____@ Comfy Seat __________@ EVAC+ALARM® Anti-Theft device __________@ EVAC+CHAIR® Patient Carrier Seat _________@ EVAC+CHAIR® Metal Storage Cabinet_______@

$__________ $__________ $__________ $__________ $__________

$__________ $__________ $__________ $__________ $__________

Shipping & Handling Charges _______ @ Total Charges

$__________

$__________ $__________

ACCESSORIES

NY State Tax (if applicable) Note: EVAC+CHAIR North America LLC Is only authorized to collect sales and use tax For the State of New York. If applicable for your State or District, please remit independently.

If paying by credit card (Must match BILL TO Name/Address) Card Number

Any Special Instructions/Comments? _________________________________________ _________________________________________ _________________________________________

Cardholder Name and Billing Address Expiration Date

CSV#

Card Type (Visa, MasterCard, Amex)


EVAC+CHAIR® North America LLC

3000 Marcus Avenue, Suite 3E6 Lake Success, NY 11042 Tel: 516-502-4240 Fax: 516-327-8220 Internet: www.evac-chair.com E-mail: sales@evac-chair.com Our Federal ID: 26-1154735

Terms and Policies Leasing Options:   

Municipal Tax-Exempt Leases for state and local government agencies. Federal Government Leases for federal government agencies including the military. Commercial Leases for small, medium and large businesses.

(Contact EVAC+CHAIR® for more details)

Return Policy: Returned Inventory Policy: Goods may be returned within 30 days of invoice date if they do not meet evacuation requirements. Customer is responsible for cost of freight to return goods to EVAC+CHAIR® North America LLC. A restocking fee of 10% will apply. Customer will also be charged for cost of any required repairs and replacement of any missing items. Customer MUST receive a returned goods authorization number from EVAC+CHAIR® North America LLC before goods will be accepted.

Terms: Our terms are Net 15 days. Prices for EVAC+CHAIRs® are FOB warehouse plus applicable taxes. Open account is available to governmental agencies, hospitals and educational institutions and firms rated "Good" or better by Dun & Bradstreet. All others should supply two major credit references or include payment with first order. Prices, specifications and equipment subject to change without notice. We accept MasterCard, Visa and American Express credit cards on our web site order form, by telephone or fax.

Sales Tax: All orders with a New York shipping address must include the applicable sales tax on both the merchandise portion and the shipping/handling charges of your order unless you provide us with an exemption permit. Shipping of accessories is FREE with the purchase of any EVAC+CHAIR®. We maintain an extensive inventory and generally ship within five days of receipt of order. Please include your street address and ZIP or Postal Code on each order.


The MK3 EVAC+CHAIR emergency evacuation system