YSI ADV6600 - Manual (Page 159)

ADV6600
Y S I Environmental
Page 149
Product Return Form
Customer Information
Organization _______________________
Contact Name ______________________
Phone Number _____________________
Method of Payment (Please Check One)
†
COD
†
Prepayment
†
Purchase Order
Number _______________________
†
Visa/MasterCard/American Express
Name_________________________
Number _______________________
Expiration Date _________________
Shipping Address
Company__________________________
Address __________________________
_________________________________
City, State, Zip _____________________
_________________________________
Country __________________________
RA Number _______________________
YSI Customer Number ______________
Fax Number_______________________
Date Shipped______________________
Billing Address
Company ________________________
Address _________________________
Reason for Return / Description of
Problem _________________________
____________________________________
____________________________________
____________________________________
Cleaning Certificate
Model Number ______________________
Lot/Serial Number ___________________
Contaminant(s) (if known):
__________________________________
__________________________________
Cleaning Agent(s) Used:
__________________________________
__________________________________
Radioactive Decontamination Certified
†
Yes (use only if product has been
†
No exposed to radiation)
Cleaning Certified By:
Name _____________________________
Date ______________________________