Return Material Authorization Form (RMA)

Incident Form / Return Material Authorization

Please complete this form and send it along with the item(s) being returned to

Intoximeters, Inc.
2081 Craig Road
St. Louis, MO 63146

If you are sending an item for repair, receipt of this completed form is required for the repair process.

Federal Law concerning the shipment of dangerous goods (Dry Gas Standards): Some versions of the EC/IR and AMCC have Dry Gas Standards housed inside. These should not be in the instruments when they are returned to us for service. The shipment of Dry Gas Standards without proper dangerous goods labeling is against the law. It can also damage the regulator and the instrument if the shipment is subject to rough handling during shipping.

Contact Intoximeters before returning a Dry Gas Standard.

Bill to Company Information

Same as Ship To

Company

Phone

Format:	(###) ###-#### or
	(###) ###-#### x###

Fax

Format: (###) ###-####

Address

Suite

City

State

Zip

Ship to Company Information

Same as Bill To

Company

Phone

Format:	(###) ###-#### or
	(###) ###-#### x###

Fax

Format: (###) ###-####

Address

Suite

City

State

Zip

All repairs are returned via ground service unless otherwise requested. If you would like a faster return method please select an option below.

Your account will be billed accordingly.

Next Day2nd DayGround

Instruments

Please click "Add Return Instrument" and enter the Instrument Model, Serial Number and Reason for Return for each item being sent for repair.

	Instrument Model	Serial Number	Reason For Return	Delete

No records to display.

Note: Intoximeters reserves the right to return the instrument in the same condition as it was received along with an invoice for the appropriate checkout charge per unit, plus all shipping charges if we do not receive a response within 15 days of the e-mailed / faxed estimate.

Authorization

Choose either Repair Request A or B

Repair Request Option A :I Authorize All Repairs
Repair Request Option B : I Request an Estimate A $40 CHECKOUT FEE WILL BE BILLED FOR EACH INSTRUMENT

Payment Option 1, 2 or 3

Payment Option 1 : No purchase order required -- work authorized by undersigned
Payment Option 2 : A purchase order number is required before checkout or repair of instrument
Payment Option 3 : Pay by Credit Card -- CC information to be collected later, work will not begin until payment is collected

PO#

(For Payment Options 2 or 3)

Authorized By

	*Contact			*Email			*Phone	Format: (###) ###-#### or (###) ###-#### x###

Please type the numbers you see below into the textbox beside it to submit the form.

772534

* Required Fields