Engler Son-Mate II, Instruction Manual

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SON-MATE II LOANER REQUEST FORM
Please review and complete this form and FAX it back to us at
305-681-3831 or 305-688-0018 so we can
ship a unit out to you.
CONDITIONS of the Engler Engineering Corporation loaner program:
1. We must receive this completed and signed form before a loaner is shipped out.
2. A Credit Card is required – the information must be shown on the form below.
3. It is understood that if Engler Engineering does not receive your unit for repair within five (5) business
days of you receiving the loaner, your credit card will automatically be charged $50.00 per week for
rental of the loaner.
4. You have five (5) business days after we send your estimate of repairs to send us your reply;
otherwise a weekly rental charge of $50.00 will be applied to your credit card.
5. Our loaner must be shipped back to us by Federal Express or UPS (NOT GROUND), to be received
within five (5) days of the date you receive your unit. You need to insure it and keep record of the
tracking number for reference if needed. If the loaner is not received, Engler Engineering will
automatically charge your card for the full value of the loaner.
6. You are responsible for all shipping charges.
7. All parts are double checked at shipping to verify that they are included with the loaner. It is your
responsibility to notify Engler Engineering at 800-445-8581 on the day the loaner is received if any
items are missing.
8. All loaner items must be returned in good working condition. We include a copy of our check list for
you to use to verify all parts are being returned. Missing and/or damaged items will be charged to
your credit card.
NOTE: Loaner requests received after 11:00 AM Eastern time will be shipped out the next business day.
Unless specified, all loaners will be shipped Federal Express - Express Saver with a 3 to 4 business day
delivery time
.
Check box if OVERNIGHT or SECOND DAY is requested at additional cost.
Please fill in the information below authorizing the transaction to accommodate your request.
Contact Name: _________________________________________________________________
Clinic Name: __________________________________________________________________
Phone ______________________________ FAX ___________________________________
Address: _____________________________________________________________________
City: __________________________________ State:______ Zip _______________________
The serial number(s) of the device being sent in is _____________________________________________
Credit card number (Amex) (Visa) (MC) _____________________________________________
Expiration:________________ Zip Code of billing address: ______________
I understand and agree to the terms and conditions stated above. Date:__________________
____________________________________________________________________________
Signature
Print Name
E03-08-00 C
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