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Fields
American PLC Warranty Repair Service Request Form
Date/Time
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Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
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Dec
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Year
2019
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Hour
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Minute
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AM/PM
AM
PM
Submited By:
*
Mary Ann - sales@americanplc.com
Linda - linda.h@aaatesters.com
Liz - orders@americanplc.com
Customer Bill To Information:
Company Name
Contact Name
*
Address
*
City
*
State / Province
*
Zip Code
*
Customer Ship To Information:
Company Name
Contact Name
*
Address
*
City
*
State / Province
*
Zip Code
*
Customer Contact Information:
Business Phone
*
Mobile Phone
Fax
Email
*
How Did You Hear Of Us?
How Would You Prefer The Item To be Shipped Back To You?
*
UPS Ground
UPS 2nd Day Air
UPS 2nd Day Air AM
UPS 3 Day Select
UPS Next Day Air
UPS Next Day Air AM
UPS Worldwide Express
UPS Worldwide Saver
UPS Worldwide Expedited
UPS Worldwide Express +
Order Information:
Invoice Number
*
Invoice Date
*
Equipment Information:
Category
*
Please Select
Micrometer / Transmitter
Starter / Contactor
PLC
Servo
Drives
OIT / MMI
Spindle
Camera / Vision
Other
Brand of Unit (Manufacturer)
*
Please Select
Allen Bradley
GE / Fanuc
Siemens
ProSoft
ABB / KEBA
Kuka
Cognex
Matrox
Keyence
Rosemount
Other
Model
*
Condition
*
Please Select
Excellent
Good
Fair
Poor
Serial Number
*
RMA Number
*
Barcode Number
Problem
*
Accessories Included With Equipment:
*
1 AC Adapter
1 Battery Pack
1 Power Cord
Memory Card
Carrying Case
User Manual
2 AC Adapters
2 Battery Packs
2 Power Cords
Other:
Other Value
Equipment Information:
Category
Please Select
Micrometer / Transmitter
Starter / Contactor
PLC
Servo
Drives
OIT / MMI
Spindle
Camera / Vision
Other
Brand of Unit (Manufacturer)
Please Select
Allen Bradley
GE / Fanuc
Siemens
ProSoft
ABB / KEBA
Kuka
Cognex
Matrox
Keyence
Rosemount
Other
Model
Condition
Please Select
Excellent
Good
Fair
Poor
Serial Number
RMA Number
Barcode Number
Problem
Accessories Included With Equipment:
1 AC Adapter
1 Battery Pack
1 Power Cord
Memory Card
Carrying Case
User Manual
2 AC Adapters
2 Battery Packs
2 Power Cords
Other:
Other Value
Equipment Information:
Category
Please Select
Micrometer / Transmitter
Starter / Contactor
PLC
Servo
Drives
OIT / MMI
Spindle
Camera / Vision
Other
Brand of Unit (Manufacturer)
Please Select
Allen Bradley
GE / Fanuc
Siemens
ProSoft
ABB / KEBA
Kuka
Cognex
Matrox
Keyence
Rosemount
Other
Model
Condition
Please Select
Excellent
Good
Fair
Poor
Serial Number
RMA Number
Barcode Number
Problem
Accessories Included With Equipment:
1 AC Adapter
1 Battery Pack
1 Power Cord
Memory Card
Carrying Case
User Manual
2 AC Adapters
2 Battery Packs
2 Power Cords
Other:
Other Value
Equipment Information:
Category
Please Select
Micrometer / Transmitter
Starter / Contactor
PLC
Servo
Drives
OIT / MMI
Spindle
Camera / Vision
Other
Brand of Unit (Manufacturer)
Please Select
Allen Bradley
GE / Fanuc
Siemens
ProSoft
ABB / KEBA
Kuka
Cognex
Matrox
Keyence
Rosemount
Other
Model
Condition
Please Select
Excellent
Good
Fair
Poor
Serial Number
RMA Number
Barcode Number
Problem
Accessories Included With Equipment:
1 AC Adapter
1 Battery Pack
1 Power Cord
Memory Card
Carrying Case
User Manual
2 AC Adapters
2 Battery Packs
2 Power Cords
Other:
Other Value
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