Document Number 900-21806 Rev C
20
R.S. Technical Services, Inc.
1327 Clegg Street
Date: ______________________
Petaluma, CA 94954
707-778-1974
MRA #
Customer Return Address:
Bill To / Distributor:
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Contact: ___________________________ Phone: ________________________ Fax: _________________________
Return Authorized by: _________________________________________________
P.O. Required # __________________________
Replacement
Estimate Required if over ____________________
Credit Invoice # ___________________
Estimate Required Before Repair
Other: ____________________________
Repair ___________________________________
Model Number____________________Description______________________________________________________
Serial Number: ___________________________________
Briefly Describe Reason for Return: _________________________________________________________________
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RST Use Only: ___________________________________________________________________________________
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