EVAC+CHAIR® North America LLC

3000 Marcus Avenue, Suite 3E6

Lake Success, NY 11042
Tel: 516-502-4240 Fax: 516-327-8220
Internet: www.evac-chair.com E-mail: sales@evac-chair.com
Our Federal ID: 26-1154735
Order Date:
Purchase Order Number:
Contact Name:
Telephone Number:
E-Mail Address for Confirmation:
BILL TO:
Organization:
Address:
City, State, Zip Code:
Attention:

SHIP TO:
Organization:
Address:
City, State, Zip Code:
Attention:

EVACUTION CHAIRS QTY ORDERED UNIT PRICE EXT. PRICE

EVAC+CHAIR® 300H (MK-3) ____ ____@ $__________ $__________
EVAC+CHAIR ®600H __________@ $__________ $__________
IBEX® 700H __________@ $__________ $__________
AIR+CHAIR® Transit Chair __________@ $__________ $__________

ACCESSORIES

Replacement Vinyl Dust Cover ____ ____@ $__________ $__________

Comfy Seat __________@ $__________ $__________
EVAC+ALARM® Anti-Theft device __________@ $__________ $__________
EVAC+CHAIR® Patient Carrier Seat _________@ $__________ $__________
EVAC+CHAIR® Metal Storage Cabinet_______@ $__________ $__________

Shipping & Handling Charges _______ @ $__________ $__________

Total Charges $__________

NY State Tax (if applicable)

Note: EVAC+CHAIR North America LLC If paying by credit card
Is only authorized to collect sales and use tax (Must match BILL TO Name/Address)
For the State of New York. If applicable for your
State or District, please remit independently.
Card Number

Any Special Instructions/Comments?

Cardholder Name and Billing Address
_________________________________________
_________________________________________
_________________________________________ Expiration Date CSV#

Card Type (Visa, MasterCard, Amex)

 EVAC+CHAIR® North America LLC
3000 Marcus Avenue, Suite 3E6
Lake Success, NY 11042
Tel: 516-502-4240 Fax: 516-327-8220
Internet: www.evac-chair.com E-mail: sales@evac-chair.com
Our Federal ID: 26-1154735

Terms and Policies

Leasing Options:
 Municipal Tax-Exempt Leases for state and local government agencies.
 Federal Government Leases for federal government agencies including the military.
 Commercial Leases for small, medium and large businesses.

(Contact EVAC+CHAIR® for more details)

Return Policy:
Returned Inventory Policy: Goods may be returned within 30 days of invoice date if they do not meet evacuation
requirements. Customer is responsible for cost of freight to return goods to EVAC+CHAIR® North America LLC. A
restocking fee of 10% will apply. Customer will also be charged for cost of any required repairs and replacement of any
missing items. Customer MUST receive a returned goods authorization number from EVAC+CHAIR® North America LLC
before goods will be accepted.

Terms:
Our terms are Net 15 days. Prices for EVAC+CHAIRs® are FOB warehouse plus applicable taxes. Open account is
available to governmental agencies, hospitals and educational institutions and firms rated "Good" or better by Dun &
Bradstreet. All others should supply two major credit references or include payment with first order. Prices,
specifications and equipment subject to change without notice. We accept MasterCard, Visa and American Express
credit cards on our web site order form, by telephone or fax.

Sales Tax:
All orders with a New York shipping address must include the applicable sales tax on both the merchandise portion and
the shipping/handling charges of your order unless you provide us with an exemption permit.

Shipping of accessories is FREE with the purchase of any EVAC+CHAIR®.

We maintain an extensive inventory and generally ship within five days of receipt of order. Please include your street
address and ZIP or Postal Code on each order.