Service Return Form

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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

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