The information provided on this application sheet aids BAL-TECH in its process of determining your equipment's eligibility for warranty coverage. By providing complete information, you are enabling us to quickly assess the equipment and aid you in purchasing the best warranty plan. Please fax a copy of current contract to 630-513-0396.

Manufacturer:		Laser Model Number:
Date of Manufacture:		Serial Number:
Description of Equipment:
Existing Contract coverage (if any) and service level (be specific):
Contract expiration date:
Pricing of current contract:
Service history or notes (shot count/hours):
Physician's office / clinic information:
Name: Tax ID#:
Address:
Phone:
Fax: Date:
Email Address:
Please call BAL-TECH Medical at (800) 574-2152 for any assistance with the above application.