ID Plaque Request Form Karl Storz

(888) 227-CASE
50 West Street. Bloomfield, NJ 07003

Thank you for purchasing a KARL STORZ Sterilization Container! Your container purchase includes two (2) custom engraved identification plaques. Please complete the fields below:

Fields marked with (*) are mandatory

Facility Name(*)

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Contact Email(*)

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City(*)

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Zip Code(*)

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Contact Name(*)

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Address(*)

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State(*)

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KARL STORZ Purchase Order #

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Available Colors: Blue, Yellow, Black, Green, Purple, Brown, Gold, Orange and Clear (Aluminum)

Please Note: "Clear" should always be ordered for STERRAD and all H202 sterilization methods. "Mini" plaques should only be ordered for Part Number: KSZ-39301AS, KSZ-39301BS, KSZ-39301C1S, KSZ-39301CS. "Reg" should be ordered for all other container styles.

Quantity

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Set Name

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Plaque Color

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Mini / Reg.

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Quantity 2

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Set Name 2

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Plaque Color 2

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Mini-Reg 2

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Quantity 3

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Set Name 3

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Plaque Color 3

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Mini-Reg 3

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Quantity 4

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Set Name 4

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Plaque Color 4

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Mini-Reg 4

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Quantity 5

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Set Name 5

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Plaque Color 5

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Mini-Reg 5

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Quantity 6

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Set Name 6

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Plaque Color 6

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Mini-Reg 6

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Quantity 7

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Set Name 7

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Plaque Color 7

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Mini-Reg 7

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Quantity 8

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Set Name 8

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Plaque Color 8

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Mini-Reg 8

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Quantity 9

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Set Name 9

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Plaque Color 9

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Mini-Reg 9

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Quantity 10

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Set Name 10

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Plaque Color 10

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Mini-Reg 10

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To receive your identification plaques, please provide the requested information and press submit button. If you don't have your PO number, please include a copy of your container sales order. Please allow up to two (2) weeks for processing and delivery.

Completed by

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Date

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Upload a copy of customer Sales Order (if any)

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