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EMC-20H Trade In Form

Form filled out by:
	Employee Name	Dealer #
Dealer
Consumer
Both  Dealer, please complete the information above
Personal Information
First Name	Last/Sur Name
Address
City	State/Province	Zip/Postal Code	Country
Home Phone	FAX	Mobile/Work
E-Mail
Certification Agency	Certification Type	Certification Number
Select From Dropdown List ACUC ANDI BSAC IANTD LAC NASDS NAUI NASSA PADI PBC PDIC SDI SSI TDI YMCA Other None	Select From Dropdown List Open Water Advanced Open Water Dive Master Asst. Instructor Instructor Instructor Trainer None
Comments (Preferred Dealer, etc.)
Where did you purchase your dive computer?
Store Name
City	State/Province	Country
Dealer #	Contact Name
Phone	FAX
E-Mail
Type of computer being traded in?
Date of purchase	Amount Paid for computer	Serial #
Do you currently use our Analyst software?		If yes, what version?
Yes No
EMC-20H Selection
Mounting	Computer Price Analyst Price Total
Select From Dropdown List Module - $995.00 Wrist - $995.00 Twin - $1205.00 Triple - $1285.00 Retract - $1105.00 Ret/Comp - $1305.00 Hose Mt - $1095.00
Case Color
Select From Dropdown List Blk Color - $0.00 LBlu Color - $20.00 DBlu Color - $20.00 Grn Color - $20.00 Gry Color - $20.00 Yel Color - $20.00 Ttm Color - $20.00
TacLite
Select From Dropdown List RedTac - $.00 YelTac - $40.00
Blends
Select From Dropdown List Air - $.00 1FO2 - $.00 2FO2 - $50.00 1FO2/1PO2 - $150.00 2FO2/2PO2 - $300.00 1FO2He - $200.00 3FO2He - $300.00 1FO2/1PO2He - $300.00 3FO2/2PO2He - $450.00
Memory Size
Select From Dropdown List 180Hrs - $.00 360Hrs - $90.00 725Hrs - $160.00 1450Hrs - $320.00
Units
Select From Dropdown List Imp - $.00 Met - $.00
Analyst
Select From Dropdown List Analyst 4.01 Pro CD & USB Module & Cable - $195.00