CIC Inc Flowmeter Recal/Repair Order Form

Customer Information

Company

International Shipping

(Please check for International orders.)

International Shipping Address

Shipping Address

City

State / Province

Zip / Postal

Country

Attn:

Is this a residential address?

Contact Information

Contact Person *

Email Address *

Phone Number

Extension:

Fax Number

Authorized Services

Service

Is this a rush order? ($35 fee per meter)

2 business day turn-around

Custom Pts.
($40 per pt/unit)

Available range 0.2 ml/min to 40.0 ml/min

Custom Pt. Measurements

Flowmeters

Flowmeter 1 *

Serial #1 *

Flowmeter 2

Serial #2

Flowmeter 3

Serial #3

Flowmeter 4

Serial #4

Flowmeter 5

Serial #5

Flowmeter 6

Serial #6

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If your unit needs to be repaired and we do not have pre-approval, there may be a delay in return delivery. If pre-approval is given and repair is un-necessary, charges billed will be for recalibration only.

If you have more than 6 flowmeters to be serviced, please provide the additional model and serial numbers in the comments field at the bottom of the form.

Payment Information

Payment Method

Credit Card Number

PO Number

Accounts Payable Contact *

Accounts Payable Email *

Accounts Payable Phone *

Extension:

Credit Card Security Code

EXP Date

Name on Card

Credit Card Statement Billing Information

Credit Card Statement Street #:

Zip Code:

Purchase Order Ref #:

Additional Email for Receipt:

-

There will be a $25 fee on all wire transfers.

Return Shipping Information

International Shipping

International

(Please check for International Orders.)

International Shipping Options

Domestic Shipping Options

Shipping Charged To:

Shipping Account:

Desired Value Protection: *

(International Only):

*(Customer assumes liability if lost or damaged in transit.) **(Not available with FedEx Services)

International Customers are responsible for all Customs Brokering, Freight Forwarding, and any other charges associated with shipping.

Comments / Additional Model & Serial Numbers

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Flowmeter Recalibration / Repair Order Form

Pricing effective January 1, 2018