Suntrac Services, Inc

1818 East Main Street

League City, Texas 77573

 

(281) 338-2133
+1 (800) 579-4513

Order Form

Ship To:

Company:

 

Attn/E-Mail:

 

Address:

 

City:

State:

Zip:

 

Tel No.:

FAX No.:

Report To:

Name:

 

Address:

 

City:

State:

Zip:

 

Tel No.:

FAX No.:

Invoice To:

Name:

 

E-Mail:

 

Address:

 

City:

State:

Zip:

 

Tel No.:

FAX No.:

 

 

1

Complete the following for each badge ordered:

Last Name

 

 

 

First Name

MI

A – ID #

B – SS#

C – Other

           Input # here:

Birth
Date

(MM/DD/YY)

Badge Type

(ref. to #4)

Ring Size

(S/M/L/XL)

Monitored Region

(ref. to #5)

Sex

(M/F)

 

 

2

Indicate frequency of service desired:

  Monthly (12 shipments/year)

Quarterly (4 shipments/year)

One time (1 shipment/inquire for price)

 

                ALL service contracts are for a 12 month period, contracts less than 12 months will be at short term rates. 

                Service will be provided continuously until written request for cancellation of service contract is received at Suntrac.

 

3

Wear Start Date:

    Q1 = 1st Day of each Quarter

    Q4 = 15th Day of each Quarter

    Q2 = 5th Day of each Quarter

    Q5 = 20th Day of each Quarter

    Q3 = 10th Day of each Quarter

    Q6 = 25th Day of each Quarter

 

4

Badge Type

5

Body Region

   14 = TLD 100

   WB = Whole Body

 

 

   16 = TLD 760 Badge

   ARE = Area

 

 

   19 = MeasuRing

   EQ = Equipment

 

 

   36 = MCP TLD

   FN = Finger

 

 

   INSTA = Instadose

 

 

 

  

 

6

Please check the appropriate billing option:

 Charge credit card            

 VISA

 Master Card

 American Express

  Card Number:

  Expiration Date:

   Credit Card Verification Code (CCV):

  Name on Card:

 

 

 Invoice with PO

 Invoice w/o PO

  PO Number:

  

  Phone/Fax:

  PO Contact:

  E-Mail:

  

 

 

 

 

 

 

 

7

TERMS & CONDITIONS

 

 

 

Renewal of Service

Additional Service Information

Service is automatically renewed, without further notice, for successive like periods unless written notification is received at Suntrac Services Inc 35 business days before the start of a renewal service period.  Cancellation includes the termination of all ancillary services, including on-line services, as of the effective date of cancellation.  All dosimeters must be promptly returned to avoid additional charges.

 

Shipment From Mirion

 

(initial order, choose one)

2-Day Shipment

$35.00

Control Dosimeter

Overnight Shipment

$75.00

A control dosimeter is supplied with each shipment for the purpose of measuring radiation exposure while the dosimeter is in transit and/or storage.  The control dosimeter must be returned with dosimeters of the same frequency period.

US Ground Mail

No Charge

Customer pays postage to return badges.

Additional Reports/Duplicate of current

***Non-Returned/Damaged Badges***

Sent to same address

$0.50 per page

ALL badges remain the property of Mirion and must be returned at the end of each exchange period.  A dosimeter (including controls) not returned 90 days after the end of the wear period, or received in damaged condition will incur a $25.00 replacement charge for each dosimeter:

Sent to different address

$0.75 per page

Copies of previously issued reports

 

Less than 3 years old (prepaid)

Base Charge

$35.00 per request

 

Copies

$0.50 per page

 

Greater than 3 years old (prepaid)

 

Base Charge

$105.00 per request

 

Copies

$0.50 per page

Services not listed will be quoted upon written request.

Form 5 – 2 Ply

$5.00 per page

 

 

 

I agree to the terms and conditions listed above in order to receive badges and badge holders.

 

 

 

 

______________________________________________

______________

______________________________________________

Authorized Company Representative (Printed)

 

Date

 

Authorized Company Representative (Signed)