POC Ultrasound CAS Activity Request

POC Applications Activity Request

"*" indicates required fields

Type of CAS Request*

Ultrasound System*

Direct or Dealer*

Direct Sales Rep*

Dealer Sales Rep*

Dealer Sales Email*

Preferred CAS*

Additional CAS for Course / Tradeshow

Start Date of Event*

Start Time

Number of Days Needed*

Will customer be purchasing in 90 days?*

Yes

If yes, when is intended purchase?*

Has opportunity budget been qualified?*

Yes

Institution Name:*

Institution Contact Name:*

Contact email or phone:*

Institution Address:*

Street Address City State ZIP Code

Course / Tradeshow Name:*

Event Contact Name:*

Contact phone or email:*

Course / Tradeshow Address:*

Street Address City State ZIP Code

Types of exams to be performed:*

Original Demoing CAS Name

Additional information on customer/event*

For Course & Tradeshows include systems

File upload - Clinical Training Form, Picking List, etc

Max. file size: 50 MB.

File upload

Max. file size: 50 MB.