Company:            Date:

Contact:            E-mail:

Phone #:          Fax #:   

THIS WORK ORDER MUST ACCOMPANY YOUR ITEM FOR REPAIR OR CALIBRATION. DO NOT SEND THIS SEPARATELY.

Item NameModel #Serial #

             

              

              

              

              

Þ *Malfunction Symptoms, Special Instructions: 

Þ *Condition of instrument: 

Þ *Requested Service: 

         BATTERY REPACK (Choose One)             Ni-Cad    OR        NiMH
BILL TO ADDRESS
Attn:  Phone:
SHIP TO ADDRESS
Attn:  Phone:

VISA || MASTERCARD || AMEX
Exp. Date:
Purchase Insurance for Return Trip?
Yes      No
Insurance Value (if requested)
PURCHASE ORDER (attach hard copy) ON ACCOUNT (need your credit info)

Service will not exceed $84.00 for repair or $129.00 for battery packs without getting an approval from the above listed company contact. The estimate is based on visual inspection of the instrument and average repair for similar equipment. The final estimate may vary during repair due to unusual circumstances and uncommon qualities of the individual equipment. There is a $56 evaluation fee. This fee is waived if the repair is approved

I WOULD LIKE MY ORDER RETURNED BY: (Please select your choice):

FED-EX: 1 Day 2 Day 3 Day Ground
Required  MY FED-X #
UPS: 1 Day 2 Day 3 Day Ground
Required  MY UPS #
DHL: 1 Day 2 Day Ground
Required  MY UPS #

This work order serves as a contract between CIH Equipment Co., Inc. and the above listed customer.

Þ SIGNATURE: ________________________________________________________________________

SHIP TO: CIH Equipment Co., Inc., 107-G Dunbar Ave., Oldsmar, FL 34677

TOLL FREE: 888-873-2443   PHONE: 813-891-6830  FAX: 813-854-1544    www.cihequipment.com