Factory Recertification Program Reservation Form Company Name:(Required) Billing Address:(Required) Shipping Address:(Required) Contact Name:(Required) Attention:(Required) Phone:(Required) Fax: Email:(Required) 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: Yes No How do you want your recertified instrument returned to you? (contact Customer Service for freight estimate) Overnight Service Second Day Service Ground Service Collect If Collect, enter Account #/Method 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) 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:
