
RETURN OF MATERIALS REQUEST
•IMPORTANT!
This form must be completed to ensure expedient factory service.
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U  | _____________________________  | _____________________________  | _____________________________  | |||||
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O  | _____________________________  | _____________________________  | _____________________________  | |||||
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E  | _____________________________  | _____________________________  | _____________________________  | |||||
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  | CUSTOMER/USER MUST SUBMIT MATERIAL SAFETY SHEET (MSDS) OR COMPLETE STREAM COMPOSITION, AND/OR  | ||||||
O  | S LETTER CERTIFYING THE MATERIALS HAVE BEEN DISINFECTED AND/OR DETOXIFIED WHEN RETURNING ANY PROD-  | |||||||
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E  | UCT, SAMPLE OR MATERIAL THAT HAVE BEEN EXPOSED TO OR USED IN AN ENVIRONMENT OR PROCESS THAT CON-  | |||||||
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C  | D  | TAINS A HAZARDOUS MATERIAL ANY OF THE ABOVE THAT IS SUBMITTED TO ROSEMOUNT ANALYTICAL WITHOUT  | ||||||
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T  | R THE MSDS WILL BE RETURNED TO SENDER C.O.D. FOR THE SAFETY AND HEALTH OF OUR EMPLOYEES. WE THANK  | |||||||
  | YOU IN ADVANCE FOR COMPLIANCE TO THIS SUBJECT.  | 
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SENSOR OR CIRCUIT BOARD ONLY: | 
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(Please reference where from in MODEL / SER. NO. Column)  | 
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1. PART NO.__________________________1.  | MODEL_________________________________1.  | SER. NO. ________________  | ||||||
2. PART NO.__________________________2.  | MODEL_________________________________2.  | SER. NO. ________________  | ||||||
3. PART NO.__________________________3.  | MODEL_________________________________3.  | SER. NO. ________________  | ||||||
4. PART NO.__________________________4.  | MODEL_________________________________4.  | SER. NO. ________________  | ||||||
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A  | 
  | REPAIR AND CALIBRATE  | DEMO EQUIPMENT NO. __________________________  | |||||
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  | EVALUATION  | OTHER (EXPLAIN) _______________________________  | |||||
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  | REPLACEMENT REQUIRED? YES NO  | _________________________________________________  | |||||
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  | DESCRIPTION OF MALFUNCTION:  | 
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  | ______________________________________________________________________________________________________  | ||||||
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  | WARRANTY REPAIR REQUESTED: | 
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  | CUSTOMER PURCHASE ORDER NO. _________________________________________________  | ||||||
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NAME _____________________________________________________  | PHONE ________________________________________  | |||||||
ADDRESS ___________________________________________________________________________________________________  | ||||||||
______________________________________________________________  | ZIP ________________________________________  | |||||||
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RETURN AUTHORITY FOR CREDIT ADJUSTMENT [Please check appropriate box(s)]  | 
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  | WRONG PART RECEIVED  | REPLACEMENT RECEIVED  | 
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  | DUPLICATE SHIPMENT  | REFERENCE ROSEMOUNT ANALYTICAL SALES ORDER NO.__________  | |||||
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  | RETURN FOR CREDIT  | RETURN AUTHORIZED BY: ______________________________________  | |||||
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  | WARRANTY DEFECT____________________________________________________________________________________  | ||||||
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Emerson Process Management  | 
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Rosemount Analytical Inc.
2400 Barranca Parkway
Irvine, CA 92606 USA
Tel: (949) 
Fax: (949) 
http://www.RAuniloc.com
© Rosemount Analytical Inc. 2001