Return Material Authorization Request

RMA Request

Complete this form to receive a Return Material Authorization (RMA) number. Please provide a purchase order number (purchase order value not to exceed $500 for circuit boards or $3500 for analyzers). You will receive an RMA # within 24 hours of receipt of this form.

(* indicates required field)

Company Billing Address

*Company Name:

*Address:

*City:

*State:

*Postal Code:

Company Shipping Address

Company Name:

Address:

City:

State:

Postal Code:

Same as Billing Address:

*PO Number:

Circuit boards not to exceed $500 each
Analyzers not to exceed $3500 each

*Contact Person:

*Phone:

Fax:

*E-mail:

*Reason for Return:

Please provide a detailed description.

Part Numbers:

*Serial Numbers:

*Method of Shipment:

	UPS
	FedEX
Account #:
	Collect
	Prepay

If repair cost will exceed PO value , an amended PO may be needed. A CIC Representative will contact you at that time to review all options.

"In Accordance with the 1998 Data Protection Act all data is kept as confidential and not passed to any third parties."