Fluid Components International FLT Series Rack Mount - Manual (Page 20)

Doc. No. 06EN003250 Rev. N/C C - 3 FLT  Series FlexSwitch  Rack Mount
APPENDIX C - CUSTOMER SERVICE FLUID COMPONENTS INTL
Document 1.
Return Authorization Request/Certificate of Non-Contamination
1. Company Name: ____________________________________________________________________
2. Contact Name: _____________________________________________________________________
3. Contact Phone No. ________________________________ Fax No.: __________________________
4. Bill to Address:_____________________________________________________________________
_________________________________________________________________________________
5. Ship to Address: ____________________________________________________________________
_________________________________________________________________________________
6. Model Number: _____________________________ Serial Number: __________________________
7. Equipment Symptom: ________________________________________________________________
Please detail the Troubleshooting Checks that were made: _____________________________________
_________________________________________________________________________________
Action To Be Taken By FCI: __________________________________________________________
_________________________________________________________________________________
Note: If calibration is required, please complete an Application Data Sheet.
8. Warranty: ___YES ___NO Purchase Order No. _______________
Note: FCI Will Assess A Minimum Charge Of $110.00 On All Nonwarranty Repairs Or Evaluations.
9. Have you contacted your local representative regarding this return?
___YES ___NO
Certificate Of Non-Contamination
____I certify that the item(s) listed below has (have) not been contaminated by a hazardous material, hazardous
substance or a toxic material or substance as defined by Federal and State law.
____I certify that the item(s) has (have) been thoroughly and completely cleaned and if the item(s) has (have) been
exposed to hazardous material, hazardous substance or toxic materials or substances that the undersigned have
thoroughly and completely neutralized such substances and any contamination which may have occurred to the
returned items. Furthermore, I understand that this Certificate shall not waive our responsibility to provide a
decontaminated product for repair to FCI.
Process Medium: _______________________________________________________________________
Company Name: _______________________________________________________________________
Authorized Signature: ___________________________________________________________________