CONEX-AGAP Agilis-D
Controller
with Strain Gages Feedback
Service Form
Your Local Representative
Tel.: ___________________
Fax: ___________________
Name: __________________________________________________ Return
authorization
#: _____________________________________
Company: _______________________________________________
(Please obtain prior to return of item)
Address:_________________________________________________ Date: ___________________________________________________
Country:_________________________________________________ Phone
Number: ___________________________________________
P.O. Number: ____________________________________________
Fax Number: _____________________________________________
Item(s) Being Returned: ____________________________________
Model#: _________________________________________________ Serial
#: _________________________________________________
Description: __________________________________________________________________________________________________________
Reasons of return of goods (please list any specific problems):__________________________________________________________________
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EDH0293En1020 — 09/12