Bristol Inc. Repair Authorization Form (off-line completion)

(Providing this information will permit Bristol Inc. to effectively and efficiently process your return. Completion is required

to receive optimal lead time. Lack of information may result in increased lead times.)

Date___________________

RA #___________________SH_

Line No.____________

Standard Repair Practice is as follows: Variations to this is practice may be requested in the “Special Requests” section.

Evaluate / Test / Verify Discrepancy

Repair / Replace / etc. in accordance with this form

Return to Customer

Please be aware of the Non warranty standard charge:

There is a $100 minimum evaluation charge, which is applied to the repair if applicable (in “returned” B,C, or D of part III below)

Part I

Please complete the following information for single unit or multiple unit returns

 

Address No.

(office use only) Address No.

(office use only)

Bill to :

Ship to:

 

Purchase Order:

 

 

Contact Name:____________________________________

Phone:

 

Fax:

 

E-Mail:

 

 

 

Part II

 

Please complete Parts II & III for each unit returned

Model No./Part No.

 

 

Description

 

Range/Calibration

 

 

S/N

 

Reason for return :

Failure

Upgrade

Verify Operation

Other

1.Describe the conditions of the failure (Frequency/Intermittent, Physical Damage, Environmental Conditions, Communication, CPU watchdog, etc.)

(Attach a separate sheet if necessary)

2.Comm. interface used: Standalone RS-485 Ethernet Modem (PLM (2W or 4W) or SNW) Other:______________

3. What is the Firmware revision? _____________________ What is the Software &version?

Part III If checking “replaced” for any question below, check an alternate option if replacement is not available

A.

If product is within the warranty time period but is excluded due

repaired

returned

replaced

scrapped?

 

to Bristol’s warranty clause, would you like the product:

B.

If product were found to exceed the warranty period,

repaired

returned

replaced

scrapped?

 

would you like the product:

C.

If product is deemed not repairable would you like your product:

 

returned

replaced

scrapped?

D.

If Bristol is unable to verify the discrepancy, would you like the product:

returned

replaced

*see below?

* Continue investigating by contacting the customer to learn more about the problem experienced? The person to contact that has the most knowledge of the problem is: ______________________________ phone_____________________

If we are unable to contact this person the backup person is: _________________________ phone_____________________

Special Requests: ____________________________________________________________________________________

____________________________________________________________________________________________________

Ship prepaid to:

Bristol Inc., Repair Dept., 1100 Buckingham Street, Watertown, CT 06795

 

Phone: 860-945-2442

Fax: 860-945-2220

Form GBU 13.01 Rev. C 04/27/06

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Emerson Process Management 9110-00A, Series 9110, CI-9110 Bristol Inc. Repair Authorization Form off-line completion