1. Please supply either your serial number and/or product equipment number and/or support agreement contract number. Please contact your local Philips Sales Representative if you cannot locate one of these numbers.
2. Start Date:
3. End Date:
4. Type of Equipment Covered Patient Monitoring Clinical Informatics IntelliSpace Event Management Diagnostic ECG Resuscitation
5. Number of site users determined by total contract value as followsless than 10K = 1 usermore than 10K but less than 25K = 2 usersmore than 25K but less than 100K= 5 usersmore than 100K = unlimited 1 user 2 users 5 users unlimited
6. User1 first name
7. User1 last name
8. User1 e-mail
9. User1 telephone
10. User2 first name
11. User2 last name
12. User2 e-mail
13. User2 telephone
14. User3 first name
15. User3 last name
16. User3 e-mail
17. User3 telephone
18. User4 first name
19. User4 last name
20. User4 e-mail
21. User4 telephone
22. User5 first name
23. User5 last name
24. User5 e-mail
25. User5 telephone
