Factory Inspection Program Reservation Form Company Name:(Required) Billing Address:(Required) Shipping Address:(Required) Contact Name:(Required) Attention:(Required) Phone:(Required) Email:(Required) What type of inspection?(Required) Standard Factory Inspection Factory Inspection with ISO 17025 Calibration Preferred Inspection Date (We will contact you to confirm the date)(Required) Instrument Name/Type:(Required)Select an InstrumentAlco-Sensor® IV & Alco-Sensor® IV with MemoryRBT IV (Alco-Sensor® IV with RBT Printer)Alco-Sensor® VXLRBT VXL (Alco-Sensor® VXL, Printer, Keyboard)TRUE-Cal DeviceIntox EC/IR® II & Intox EC/IR® II.t Instrument Serial Number(s):(Required) If repairs are required to certify the performance of my instrument, in addition to the Inspection fee, I (check the appropriate box below):(Required) Pre-approve all repairs Pre-approve repairs up to $300 (not including taxes or freight) Do not pre-approve repairs. Send me an estimate for approval ($40 fee applies). How do you want your inspected instrument returned to you? (contact customer service for freight estimate) Overnight Service Second Day Service Ground Service Collect If Collect, enter Account #/Method Payment Terms (Note: Purchase order or credit card information is required before scheduling will occur.) New Customer Net 30 days (for est. accounts) Credit Card Bill My Account #: PO#: Email to send invoice: Name: Phone Number:
