Fields marked with an asterisk (*) are required.

Company:*

RSO:

E-mail:*

Phone:*

Fax:*

How often do you want
to receive badges?*

Monthly 
Quarterly

How often do you
want to be billed?*

Annually
Quarterly

What date to want
to start service?*

Shipping Address

Attention:

Street:*

City:*

State:*

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ZIP:*

Ship Badges By:
(For This Order Only)

Billing Address

Same as Shipping Address
(If checked, leave the fields below blank.)

Attention:

Address:

City:

State:

ZIP:

PO#:

Personnel to be Badged

Full Name

Sex

Birthday

Badge Type

FOR RUSH ORDER ONLY: Special Shipping Address
(if applicable, for this order only; otherwise we will ship to the address entered above)

Company:

Address:

City:

State:

Alabama Alaska Arkansas American Samoa Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Marshall Islands Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington Wisconsin West Virginia Wyoming

ZIP:

Phone:

Terms & Conditions

1. The initial term of this agreement is one year unless otherwise specified. Rates quoted at time of order will remain in effect for the initial term.
2. This agreement will be renewed automatically for successive one-year periods, unless written notification to cancel service is received at least 30 days before the renewal date. Rates and terms for all successive periods are subject to change.
3. All badges (dosimeters and holders) remain the property of Troxler Radiation Monitoring Services.
4. Badges not returned to Troxler or returned more than ninety (90) days after the end of the monitoring period are subject to a late/lost badge charge.
5. Requests for changes in service (add or delete badges) must be received at least thirty (30) days before the monitoring period in which the changes are to be effective.
6. Troxler will charge for all service provided prior to cancellation. A cancellation fee will be charged if service is canceled prior to the end of the annual agreement period.
7. An invoice for the first year of service will be issued after the first badge shipment. Payment is due within thirty (30) days. A late charge of 1.5% per month, 18% annum (or lower rate as applicable state laws allow) will be applied to any balance past due more than thirty (30) days.
8. Adjustments to accounts for badges added or deleted or other services requested will be charged or credited at the next regular billing period for the account.

I agree to all the above terms and conditions and authorize the purchase of this service:

Name of person completing form*

Date* (mm/dd/yyyy)