Return Material Authorization Form
Ship To: PI Components NV
Griffinstraat 4-6
B-2170 Merksem
Belgium
For factory use only!
Handled by: Your name
RMA #:
Your Address
Your Postal Code + City, Country
Phone number
SR / PO #:
Fax Number
Ship to info Customer Order details
Company name: Customer Order Ref #
Attention: Quotation required? Yes No
Adress: Investigation report required? Yes No
Postal Code / City: Warranty Claimed? Yes No
Country: Original order #:
Phone: Delivery Date:
Fax:
Reason for claim:
email:
End user same as ship to address.
When end user is not the same as the ship
to address, please provide end user data:
End use:
Instrument Details Installation details
Model # / Type #: Remote seal? Yes No
Assembly # / Part #: On Side? High Low
Serial #:
Description or model #
Tag name / #:
4-20 mA (or HART)
Description: Signal Type:
Foundation Fieldbus
Problem Description:
Repair Replacement Model # Change
(Re) Calibation Return on Advanced Replacement Upgrade / Modify
The goods are returned for:
Other:
Required Modification / calibration
/ Change / etc.:
Application Details
Process medium:
Operating temperature: min. normal max.
Operating pressure: min. normal max.
By signing and returning this RMA Form I confirm that the equipment has been cleaned and decontaminated in accordance with good industrial practices and
in compliance with all regulations. This equipment poses no health or safety risk due to contamination.
If applicable, I attach corresponding International Chemical Safety Cards for the media the equipment was exposed to.
Also I agree that by returning above mentioned goods I will at least be charged with the minimum examination costs (110,00 Euro)
Name: Signature:
Department:
Date:
In order to avoid delays please ensure that all applicable fields are completed. Completed forms (one per device) to be mailed to Picomponents.repair@picomponents.net
or faxed to +32 3 641 6868 and equipment to be sent to above mentioned "Ship to:" address with a copy of the completed form(s) on the packaging. Only use this form to
request RMA. Do not send equipment before receiving a RMA!
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