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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
to Bristol’s warranty clause, would you like the product:
repaired returned replaced scrapped?
B. If product were found to exceed the warranty period,
would you like the product:
repaired returned replaced scrapped?
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