ORDER FORM FOR THE LARGE MRI ACCREDITATION PHANTOM

Phone: 858-794-7200
Fax: 858-704-4959
Fed ID: 20-2145542
DUNS: 066562083
ORDER FORM FOR THE LARGE MRI ACCREDITATION PHANTOM
J.M. Specialty Parts Item: ACR-PH1
For Scanners Designed for Full Body Examinations
Dimensions: 8” Diameter, 6-3/4” Cylinder Length, 7-1/4” Length with Level Bar
Notice:
• Returns are subject to a $200 restock fee and your facility pays the overnight return shipping.
In order to process your phantom order in a timely manner please complete all of the following.
1 – Complete the Phantom Order Form for each address you would like a phantom shipped to.
(Lower portion of this sheet) Please supply all information.
2 – Payment: California sites add local sales tax.
Purchase orders are not accepted.
Discount Price: Check, paid to J.M. Specialty Parts, Inc. for $1,295.00 USD.
Next day air shipping and handling is included inside the 48 contiguous states only.
The fee for returned checks is $20.00
OR
Full Price: MasterCard, Visa, and Discover (NO Amex) $1,345.00 USD.
accepted from USA and territories only.
3 – Send completed order form and check to:
J.M. Specialty Parts, Inc.
11525 Sorrento Valley Rd.
OR
Suite – B
San Diego, CA 92121
Fax or e-mail completed order form
and completed credit card authorization to:
Fax 858-704-4959
Email: [email protected]
Your ID Number from ACR: MRAP
• If ACR has not assigned your MRAP number then leave this line blank and call J.M. Specialty
Parts later when you receive your number.
• If you are not applying for accreditation, indicate the purpose (resale, research) of your phantom
purchase.
REQUIRED INFORMATION:
Facility Name and Shipping Address as it should appear on the shipping label: NO P.O. Boxes
Name of Contact Person:
Phone:
Fax:
E-mail:
Outside the 48 Contiguous United States (and all other countries), shipping is not included.
Your Shipping Company’s Name:
Your Billable Account Number:
The shipping company (FedEx, UPS, DHL) will bill you for shipping, customs, VAT and any other import cost.
•
For a quote on prepaid shipping cost, fax or email a copy of your completed phantom order form. Specify the
items to be on the quote (phantom and shipping, shipping only) and the reply method, fax or e-mail.
Fax: 858-704-4959
Email: [email protected]
Rev. 1/2015
11525 SORRENTO VALLEY RD
SUITE - B
SAN DIEGO, CA 92121
T: (858) 794-7200
F: (858) 704-4959
E: [email protected]
CREDIT CARD AUTHORIZATION
In order to process a credit card purchase we must have all of the following information.
Please print all entries clearly except signature.
No Amex
Circle One:
VISA
MASTER CARD
DISCOVER
Name on the credit card:
(Exactly as it appears on the card.)
Account Number: ______________ - ______________ - ______________ - ______________
Expiration Date:
Dollar amount authorized to charge:
CVV2/CDI:
$ __________________________
Address the credit card bill is sent to:
Zip Code the credit card bill is sent to: ________________________________
Full name of authorized person: _____________________________________________
( print )
Signature of authorized person:
Date: ______________________________
Rev. 1/2015