Note: * means required input field

 Customer Information:
       Company Name*: 
          Your Name*: 
              Phone*: 
                Fax*: 
     E-mail Address*: 
    Ship to Address*: 
                      
               City*:  State*:  Zip*:  

Order Information:

   Number of handheld terminals needed*: 
   
   Latest date equipment can arrive:      JanFebMarAprMayJunJulAugSepOctNovDec    12345678910111213141516171819202122232425262728293031

   Date equipment will be shipped back:   JanFebMarAprMayJunJulAugSepOctNovDec    12345678910111213141516171819202122232425262728293031

Type of Equipment:
   Model*:            T2425 - Open Air Radio2435 - 802.11b Radio
700 Series PPC Batch
700 PPC w/802.11b
Janus 2020Trakker 9440 with wand scanner
CK31
AML 7100 Series
Cipher Batch UnitsScannersOther 

   Mode/Emulation:    VT Terminal Emulation 5250 Terminal EmulationRF - not Terminal EmulationBatch program
3270 Terminal Emulation
Scanner Only

Special Information:

           

Payment Information:
   
   Rental period is per week (5 consecutive work days).

   Credit Card is required for security and to reserve equipment.  We will bill against a 
   purchase order if faxed to (703) 783-0319.  PO #: 

  Visa  MasterCard  American Express  card on file (please update Exp. Date)

                        Card #:  Exp. Date: 
   Name on Card (if not yours): 

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