Supply Form | Figment Group Inc.

Lifeloc Equipment and Supply Order Form

Instructions

Shipping & Handling Charges will be added to your total purchase.

Please complete the order form completely.

To select an item, choose your quantity.

To submit your order, please click on the Captcha—–I am not a robot box, then click the Submit Order button at the bottom of the form.

For equipment and supplies not listed on this order form, please contact Figment Group, Inc. at 219.326.8880 or by E-mail.

Company / Clinic *

Name of Individual Placing Order *

Email *

Phone *

Billing Address *

Country

City

State

Zip code

Shipping Address *

Country

City

State

Zip code

Attention *

Shipping Method *

Normal - 5 to 7 Business Days

Next Business Day - Extra Fee

P.O. Number

Mouthpieces

Phoenix 6.0 EasyTab (100 pcs/pkg) - Your Cost: $23.60/pkg

Part No. 13043 - List: $24.60/pkg

Phoenix 6.0 EasyTab (250 pcs/pkg) - Your Cost: $56.45/pkg

Part No. 13046 - List: $58.45/pkg

Forms

DOT Forms (Perforated Top - 100/pkg) - Your Cost: $26.00/pkg

Part No. 14010 - List: $27.30/pkg

Non-DOT Forms (Perforated Top - 100 /pkg) - Your Cost: $26.00/pkg

Part No. 14008 - List: $27.30/pkg

Printer Labels

PermAffix Printer Labels (140 labels/roll) - Your Cost: $23.45/roll

Part No. 14107 - List: $25.45/roll

PermAffix Printer Labels (4 roll pack) - Your Cost: $81.95/roll

Part No. 14197 - List: $83.95/roll

Bluing Tablets

Bluing Tablets (100 Tablets) - Your Cost: $13.29/bottle

Part No. 19003 - List: $14.29/bottle

Bluing Tablets (3 pk-100 Tablets Each) - Your Cost: $35.86/3-pk

Part No. 19064 - List: $37.86/3-pk

Dry Gas

.040 Dry Gas Cylinder (34 liter) - Your Cost: $132.00/cyl

Part No. 15011 - List: $141.00/cyl

.100 Dry Gas Cylinder (34 liter) - Your Cost: $132.00/cyl

Part No. 15005 - List: $141.00/cyl

Calibration Supplies – Adapter & Regulator

Calibration Adapter Kit - Your Cost: $4.95/kit

Part No. 15308 - List: $5.15/kit

Regulator - Your Cost: $106.50/unit

Part No. 15302 - List: $115.50/unit

Cables & Chargers

PermAffix Printer Cable - Your Cost: $68.00/unit

Part No. 17005 - List: $68.00/unit

PermAffix A/C Charger - Your Cost: $186.00/unit

Part No. 17102 - List: $196.00/unit

Batteries

Printer Battery Pack PermAffix (SATO) - Your Cost: $85.00/unit

Part No. 17203 - List: $85.00/unit

Bluetooth Printer Battery Pack (Toshiba) - Your Cost: $87.60/unit

Part No. 17206 - List: $87.60/unit

AP 1310 Printer Battery Pack - Your Cost: $60.75/unit

Part No. 17204 - List: $60.75/unit

Captcha *

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