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IOM BiRotor 3” to 6” R03
Appendix B
Customer Problem Report
Company Name: ____________________________________
Technical Contact: __________________________________
Repair PO#: ________________________________________
Invoice Address: ______________________________
_______________________________
_______________________________
Shipping Address: ____________________________
______________________________
______________________________
Return Shipping Method: _____________________________
Equipment Model #: _________________________________
Description of Problem:______________________________
___________________________________________________
___________________________________________________
What was happening at time of failure: _________________
___________________________________________________
Additional Comments: _______________________________
___________________________________________________
Report Prepared by: _________________________________
Phone: ______________________________________
_____
_____
_____
_____
_____
_____
S/N:_________________________________________
Failure Date: __________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
Title: ________________________________________
For faster service, complete this form and return it along with the affected equipment to customer service at
the address indicated below. If you require technical assistance, please contact the Product Service Depart-
ment at the phone number listed below.