New Customer Form : Associated X-Ray Imaging Corporation X-Ray System Sales & Service

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SHIP TO: (If different from above)

SHIP TO ATTENTION:

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Ship to Fax #:

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Doctor's Name:

Purchasing Name:

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Purchasing Phone #:

Doctor's Fax #:

Purchasing Fax #:

Doctor's Email:

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Radiology Name:

ACCTS Payable Name:

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Accts Payable Phone #:

Radiology Fax #:

Accts Payable Fax #:

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