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| Device: | Name: |
| Max kVp: | Address1: |
| Max MA: | Address2: |
| Age of Unit: | City, State, Zip: |
| Model No: | Area Code and Phone: |
| Principle Design Use: | Area
Code and Fax:
Area Code and Cell: |
| Condition of Device: | |
| Asking/Offering Price: | email: |
| Additional Info: | |
| Fee:
[ ] 30 days $50
(check one)
[ ] 60 days $40 [ ] 90 days $25 ($25 for each additional 30 days) or [ ] WANTED $20 for each 30 days |
Send Payment To: John
R Haygood
1779 Wells Branch Pkwy #110B - PMB 282 Austin, TX 78727 Note: Form must be printed and mailed. |
| Notice:
By submitting this request form you acknowledge your understanding that
x-ray devices are required to be registered
in each state and that it is your responsibility to inform the recipient
of this requirement.
NOTE: Listing will not be posted until payment is received. |
Notice:By submitting this form you indicate that you understand, acknowledge, and accept that the various laws, rules, regulations, and requirements of regulatory agencies are continually changing. You further understand, acknowledge, and accept that John R. Haygood, Southwestern Bell Internet Services(TM), Netscape Communications Corporation, MicroSoft, and other involved internet companies and entities are not responsible for errors, omissions, changes, accidents, and other problems associated with the transfer of information via electronic, mail, or delivery systems, nor for any transfer of property. You accept responsibility for complying with the regulatory agency(s) requirements and do not hold responsible any of the aforementioned parties. |
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INSTRUCTIONS and EXAMPLES: Device: Enter the basic type of device - Medical X-ray, Dental X-ray, Industrial X-ray Diffraction, etc. Max kVp: When applicable, enter the manufacturer's rating. Max MA: When applicable, enter the manufacturer's rating. Age of Unit: Enter the year of manufacture. Model No: Enter the manufacturer's model number designation for the unit. Principle Design Use: If applicable, enter
the type of use that the device originally was designed for. Indicate
whether medical,
Condition of Device: Use your own judgement. Asking/Offering Price: Optional. Additional Info: Add any information that might be useful to a potential user. Note: This form is not editable. You
must print it, add the information, and fax or mail it to the indicated
fax number or
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