Doc. CEI12166
Rev. 1
Pag. 42 Of 47
INSTRUMENT RETURN FORM
DATE ____________ AGENT _________________ COUNTRY ___________________
TYPE OF INSTRUMENT ____________________ SERIAL NO. __________________
INSTRUMENT RETURNED FOR: CALIBRATION ____ REPAIR ____
In case of repair, please specify the following.
DATE OF FAULT _______________ REPORTED BY E-MAIL, PHONE ___________
COMPANY _____________________ USER’S REFERENCE ____________________
FAULT DESCRIPTION ____________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________
HOW DID IT OCCUR ______________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
___________________________________________________________
LOCAL ANALYSIS OR ATTEMPTS TO REPAIR _______________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
___________________________________________________________
RECOMMANDATIONS AND NOTES _________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________