MIRT Dealer Name: SteveKraft.com

 MIRT Dealer Number 1988993

 Phone: (630) 801-1984

Fax: (630) 801-0569

CUSTOMER ORDER FORM

Manufacturer’s statement: The MIRT traffic signal preemption emitter is a restricted sale device. By executing this document the party named below agrees to all information contained herein. It is the express purpose of the manufacturer to prohibit the use of traffic signal preemption products by unauthorized individuals by restricting the sale of such devices to those departments and individuals that are legally entitled to use them. The manufacturer reserves the right to refuse sales at its discretion.

Customer Information:

I wish to purchase the following number of units of THE MIRT for official use:

# of units (THE MIRT, Part No. MIRT-VT): 1 x (sales price) $ ________Sub Total: $__________    

                                                                            Sales Tax $_________TOTAL $____________

Payment options:      CC ____________________________      EXP DATE _______________   Card Verification Number ________________

                                                                                                                                          (On the back of your card, locate the final 3 digit number)  

                                  CASH                                PURCHASE ORDER

                                  MONEY ORDER                 PAYPAL

Name:________________________________________

                                              (please print)

Title/position:_________________________________________________________________

Organization:_________________________________________________________________

Address:

Street_____________________________________

City______________________ State____________________ Zip code__________________________

Phone number (____)______________________ e-mail address_________________________________

Ship-to Address: (if different from customer address above):

Attention ______________________________________________________________________

Street_________________________________________________________________________

City__________________________ State____________________ ___Zip code________________

(other shipping notations)

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Customer Agreement:

       I am authorized to purchase THE MIRT, traffic signal preemption emitter. By signing below,

I agree to the manufacturer’s statement of restricted sale (at the top of this page). The unit/units purchased will be used in accordance with all local, state, and federal laws regulating traffic signal preemption.

Signature_____________________________________________ Date_________________________: