Service Return Form
You may fill out this form on your computer or print a copy to complete by hand.
Print one copy for your records, and one copy to include with your instrument(s).
► Your Instrument’s Serial #(s)
_____________________________________________________________________________
► List accessories included in shipment: (Required accessories notated with *)
Quantifit/FitTester 3000
Noise Instruments
Audiometers
Tube Assembly*
Vinyl Pouch
doseBadge Mounts
Headphones*
Power Cord
Computer Cable
Windscreens
Bioacoustic Simulator*
Printer
Keyboard
AC Adapter
Trigger Button* or Squeeze Bulb*
Carry Case
)
Adapters (Kit #’s:
Keyfob
____________________
Other:
____________________________________________________________________________________________
NOTE: We are not responsible for non-OHD accessories shipped with service units.
► Reason for return:
Warranty
Calibration
Repair/Other
► Payment Information
(This section must be completed in order for us to service your instrument):
Warranty Repair
Pre-Paid Calibration
Purchase Order#
Maximum Amount Authorized:
_____________________________
___________________
We do require a copy of your purchase order.
Purchase order copy is:
Enclosed
Being Mailed
Being Faxed
Credit Card: Type: ___________ Number: ______________________ Exp: ________ CID:______
► Describe any known problems:
_________________________________________________________________________
___________________________________________________________________________________________________________
► Before/After Data Needed? Yes
No
(Additional charges will be applied)
Please note: Requiring an estimate before work delay service return time.
Billing Address
Shipping Address: ( check here if same as billing)
Company Name:
Company Name:
___________________________________
___________________________________
Address:
Address:
___________________________________________
___________________________________________
City/State/Zip:
City/State/Zip:
______________________________________
______________________________________
Contact Name:
Contact Name:
_____________________________________
_____________________________________
Phone:
Phone:
_____________________________________________
_____________________________________________
Fax:
Fax:
________________________________________________
________________________________________________
E-Mail:
E-Mail:
_____________________________________________
_____________________________________________
To expedite your repair:
Please include a copy of this form when shipping your instrument.
It is required that one Service Return Form be completed for each unit (Except for doseBadge Kits).
Terms are net 30 days OAC. No RMA number is required.
Return equipment, billing information and all correspondence to:
Occupational Health Dynamics
2687 John Hawkins Parkway | Hoover, AL 35244
Phone: (888) 464-3872 | Fax: (205) 980-5764
03/01/15