Lakeshore Technologies - Information Request

Information Request

Thank you for your interest.

Please provide us with any information you can about your current system and how to contact you so we may help.

* Indicates Required Field

System Information:

System	(Manufacturer, Model)
System Type	(Fluoro, R/F, Cardiac)
II Model / Part Number	(If Known)
Camera System	(Manufacturer, Tube, CCD,)
Monitors, Number / Type	( Single, Dual, CRT, Flat)

Current System Status:

Operational?
Not Operational?
Status	(i.e. Poor image quality)

Addition Information:

Please provide any additional information:

Previous Lakeshore Technologies Customer?

Yes
No
If Yes, When?

Your Company:

Company Name
Address 1
Address 2
City
State
Zip Code
Phone

Your Information:

*First Name
*Last Name
*Phone
*Email
*Confirm Email

We respect your privacy. We only use the information provided to fulfill your orders and/or to contact you. Your private information will never be shared with anyone.

By selecting "Send", you certify that the above information is true.

* Permission for Lakeshore Technologies to contact me.

Please enter the number shown and Click "Send": 30529