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

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