Pre-Course Planning Worksheet Pre-Course Planning Worksheet*An asterisk denotes a required field.Contact InformationRequestor Name* First Last Job Title* Phone Number* Email - Requestor* Enter Email Confirm Email Hospital Name* Hospital Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Training EventTraining Date(s)* Course Options* One Day Course - $5,095 Two Day Course - $6,495 Three Day Course - $7,895 Four Day Course - $9,295 Five Day Course - $10,695 Select the number of days above and then the course(s) from the options below. The price listed is the same for up to five students. Each additional student is $395 per student.One Day Course* LigaSure Vessel Sealing Generator Force EZ Electrosurgical Generator FT10 Energy Platform Number of Students*123456 (+ $395)7 (+ $790)8 (+ $1185)9 (+ $1580)10 (+ $1975)Two Day Courses* Force FX -C ForceTriad Number of Students*123456 (+ $395)7 (+ $790)8 (+ $1185)9 (+ $1580)10 (+ $1975)Three Day Courses* Force FX -C & ForceTriad Force FX -C & FT10 ForceTriad & FT10 Number of Students*123456 (+ $395)7 (+ $790)8 (+ $1185)9 (+ $1580)10 (+ $1975)Four Day Courses* Force FX -C, ForceTriad & FT10 Number of Students*123456 (+ $395)7 (+ $790)8 (+ $1185)9 (+ $1580)10 (+ $1975)Five Day Courses* Force FX -C, ForceTriad, FT10 & Force EZ Force FX -C, ForceTriad, FT10 & LigaSure Number of Students*123456 (+ $395)7 (+ $790)8 (+ $1185)9 (+ $1580)10 (+ $1975)Training EquipmentIt is required that the hospital provide the electrosurgical generators (type and number) for training. We recommend one generator for every three students.Will you be able to meet this requirement? (If no, there will be a charge of $300 per generator)* Yes No Biomed Support Services provides generator rentals. If you are interested in this option, please select how many of each generator you would like us to bring.Force FX -C* 0 1 (+ $300) 2 (+ $600) 3 (+ $900) 4 (+ $1200) 5 (+ $1500) ForceTriad* 0 1 (+ $300) 2 (+ $600) 3 (+ $900) 4 (+ $1200) 5 (+ $1500) FT10* 0 1 (+ $300) 2 (+ $600) 3 (+ $900) 4 (+ $1200) 5 (+ $1500) Rental Charge Agreement* I understand that the rental fee is in addition to the cost of training and will be charged as a separate line item on the invoice. This extra charge may require an amendment to the NTE amount specified on the original purchase order. Shipping/Training FacilityPoint of Contact* First Last Work Phone* Cell Phone* Email - Point of Contact* Enter Email Confirm Email Building Name* Building Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Does this facility have a shipping dock?* Yes No If yes, does the dock have a lift gate/plate?* Yes No Specific delivery and pick-up hours?* Can the training equipment crate arrive early?* Yes No Recommended airport* Is there a security check-in requirement?* Yes No If yes, explain* Is the in-house WiFi accessible?* Yes No If yes, how?* CommentsPayment InformationTotal $0.00 The total price reflects course options, generator rentals and additional students over five.Payment Method*Credit CardPurchase OrderPurchase Order #* If you have questions submitting a PO please call 303-525-3393.Credit Card #* No dashes.Name on Credit Card* Expiration MM/YY* Credit Card Code* HiddenAgree To Terms* I have read and agree with the Cancellation Policy
