* Sales Rep Requesting

* Sales Rep's email address

Event Information

• * Name
• * Date of Event
• * Date Needed to Arrive

Shipping Information

• * Picking up or shipping? Shipping Picking up
• * Ship to (Facility)
• * Contact's Name
• * Contact's Phone Number
• * Shipping Address
• *Lift Gate Required (Y or N) Yes No
• * Estimated Date of Return

Cart Information

All HI-Care based carts are white/grey with 5" casters unless specified.
Monitor measures up to 22" unless specified.

• * Cart Needed:
• CPU:
• Monitor:
• Peripherals:
• Accessory mounting options:
• Pole with mounting bracket
• Extended Mounting Bracket
         Not compatible with HI-Care general storage drawer or HI-Paradigm.
• Accessories:
• Sani wipes Mini waste Basic Accessory Pack
  Includes pole, extended
  mounting bracket, Sani-
  wipes, bracket,1 QT
  sharps container, Mini
  waste bin, Small basket,
  and Hand Sanitizer
• Hand sanitizer Small basket
• Sharps 1 QT Large basket
• Sharps 2 QT

Additional comments about Shipping

Additional comments about Cart, Drawer Configuration, Power System:

Marketing Materials Quantity

* Shipping to same Location as above Yes No

If Different:

Flooring

Tablecloth(s)

Pop-up Banner Stand

Givaways

Additional comments about Marketing Materials

Brochures

HI-Mobile HI-Paradigm

HI-Care HI-Pinnacle

HI-Prodigy Tri-fold Folder