Additional Options

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For New Accounts

Fields marked with an asterik (*) are required.

Shipping Address 

Billing Address

Personnel To Be Badged

Full Name


Date of Birth

Badge Type
For Rush Order Only: Special Shipping Address (if applicable, for this order only; otherwise we will ship to the address entered above)
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 sixty (60) 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-five (35) 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)
* Required