IREMSC Equipment Request Form

Please verify that all information is correct before sending.

Please see the IREMSC store catalog available on this site for a list of equipment & supplies that are available.

**Please note we only ship within Alaska.

Just complete this form. Click on Submit when ready to send.

Email address:

Shipping Address

   

Billing Address

Please type same as above if not different than shipping address.

Daytime Phone Number

   

How would you like your order shipped?

Customer will pick up
US Mail Service
Federal Express
Freight Service*please not that a $30 delivery charge will be billed to deliver your items to the freight office.

         What date is the equipment needed?

 

      

How long will you need this equipment?

Equipment List

Item ID Amount Description

Any comments?