* Sales Rep Requesting

* Sales Rep's email address

Alternate email address

* Opportunity size

Event Information

• * Name of Event
• * Date of Event  
• * Date Needed to Arrive  
• * Expected Date of Return  
• * Ship to Facility
• * Contact Name   
• * Contact Phone Number   
• Contact Email   
• * Pickup or Shipping? Pickup Shipping
• * Shipping Address
• *Lift Gate Required (Y or N) Yes No

Cart Information

All HI-Care based carts are Gray/White, Lithium Powered, with Howard
LCD arm, 5" casters, and double spacers unless specified.Monitors measure
up to 22" unless specified.

• * Cart Needed: HI-Care HI-Mobile HI-Paradigm HI-Pinnacle (Small) HI-Pinnacle (Medium) Transfer Cart Med Hub None
• * Monitor: Dell HP All-In-One Any None
• * CPU: Dell Laptop Dell SFF HP Laptop HP SFF Tablet All-In-One Any None
• * Storage Type: 1-Tier General Storage HI-Care 2-Tier ELS HI-Care 2-Tier Prodigy 4-Tier Summit 3-Tier Paradigm Hi-Pinnacle None
• * Locking Method: Basic Electronic Advanced Electronics Key Locking Detent only N/A
• Drawer configuration:
• Peripherals:
• •  Mouse
  •  Keyboard
  •  Docking station
  •  Fixed Scanner

  •  Tethered Scanner
  •  Wireless Scanner
  •  Universal Scanner Mount
  •  Halogen Lamp

  •  Keyboard Light
  •  Negative Tilt Keyboard
  •  
  •  
• Other - if other, please specify
  
• * Accessory mounting options: Pole with mounting bracket Extended Accessory Mount Pole and Extended Accessory Mount None
• Accessories:
• •  Sani Wipes
  •  Hand Sanitizer
  •  Sharps 1 QT
  •  Sharps 2 QT
  •  

  •  Mini Waste
  •  Small Basket
  •  Large Basket
  •  Small Cup Holder
  •  Large Cup Holder

  •  Basic Accessory Pack
    
    (Includes pole, extended
    mounting bracket, Sani-
    Wipes, bracket,1 QT
    Sharps Container, Mini
    Waste Bin, Small Basket,
    and Hand Sanitizer)
    
  •  

Additional comments about Shipping

Additional comments about Cart, Drawer Configuration, Power System:

Marketing Materials Quantity

* Shipping to same Location as above Yes No

 Flooring

 Tablecloth(s)

 Pop-up Banner Stand

 Giveaways

Additional comments about Marketing Materials

Brochures

 HI-Mobile  HI-Paradigm

 HI-Care  HI-Pinnacle

Hub/Transfer