Factory Inspection & Recertification 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 Preferred Inspection Date (We will contact you to confirm the date)(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). What type of recertification?(Required) Standard Factory Recertification Standard Factory Recertification with ISO 17025 Calibration Preferred Recertification Date (We will contact you to confirm the date)(Required) Will you require a Rental Unit:(Required) Yes No 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) How do you want your inspected or recertified 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:
