Intoximeters, Inc.
Return Authorization Form
Please complete this form and send it along with the item/s being returned to
Intoximeters
8110 Lackland Road
St. Louis, MO 63114
If you are sending an item for repair, receipt of this completed form will expedite the repair process.
This form is also being sent to Intoximeters.

BILL TO COMPANY NAME & ADDRESS:
 SHIP TO COMPANY NAME & ADDRESS:
Phone Phone
Fax Fax
Email Email

INSTRUMENT MODEL

SERIAL #

 REASON FOR RETURN
List any unusual circumstances, prior history of the equipment, or operating conditions which might have a bearing on the cause for return.

--> A $75.00 CHECKOUT FEE TO COVER LABOR COSTS WILL BE BILLED FOR EACH INSTRUMENT <--
PLEASE COMPLETE THE FOLLOWING IF YOU ARE SENDING AN ITEM FOR REPAIR.
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.
PURCHASE ORDER OPTIONS: PLEASE SELECT & COMPLETE OPTION A OR B BELOW

A

  A purchase order number is required before checkout or repair of instrument:

B

  A purchase order number is not required but the work is authorized by the undersigned:
PO# Print Name
       

 

I AUTHORIZE ALL REPAIRS:

I REQUEST AN ESTIMATE:   Note: A $75.00 checkout fee to cover labor costs will be billed for each instrument.

By: E-MAIL or FAX#  

 

AUTHORIZED BY: 

Contact        Date Phone

Please type the numbers you see below into the text box beside it.
43849    
  

Please see the attached Technical Service sheet for additional service
information or refer to our Website at www.intox.com.
*A restocking fee may be applied for returned merchandise.*