REPAIR REQUEST FORM

PLEASE READ

To expedite the repair of your equipment, you can send this form either by *FAX or **E-MAIL.
Please complete this form, print, and enclose it in the package with the equipment.

* FAX: Please complete and print out this form and fax it to +44 (0) 20 8 291 9678.

**E-MAIL: Please complete this form and click the send button below.

1: *MODEL NO. *SERIAL NO.
*PLEASE DESCRIBE THE PROBLEM WITH THE EQUIPMENT

2: *MODEL NO. *SERIAL NO.
*PLEASE DESCRIBE THE PROBLEM WITH THE EQUIPMENT

CUSTOMER INFORMATION

*NAME:
*TELEPHONE:
FAX:
*E-MAIL:
(Confirm)
UNIVERSITY or COMPANY
ADDRESS:
POSTCODE:
COUNTRY: