Milco Safety Rental

Rental Request Form

NOTE: Our rental form does not have a "shopping cart" feature yet. Please make notes of the items you are requesting & complete this form. Print this form prior to its submission for your records. Once the form has been submitted, all data on the form will be lost.

Billing Information
Invoice Address:
Company Name:
Street Address:
City, State Zip	,
Phone Number:
Email Address:
Purchase Order/Job Number:
Shipping Information
Name:
Company Name:
Street Address:
City, State Zip	,
Phone Number:

Instrument Arrival Date:	Early AM AM PM
Rental Start Date:
Instrument(s) Required:	1. 2. 3. 4. 5. 6.
Consumable/Accessory items required (include size, quantity, specs. etc):

MSR, Inc. will make every effort to ship your product on 2nd basis to reduce your shipping costs. Please return the instruments via an overnight courier to reduce your rental costs. MSR, Inc will notify you of our receipt of your order. Thank you for considering MSR, Inc.

Rental Request Form

Billing Information

Shipping Information