REPAIR REQUEST FORM

Please complete the form below. Print it and fax it to 631-841-0066. Please be sure to enclose the completed form in the package when you send the equipment to us.

**DO NOT use Federal Express to send unit to Narishige from outside U.S.A.**

DATE: / / (mm/dd/yyyy)

Repair Department
Narishige International USA, Inc.
415 Bayview Avenue, Amityville, NY 11701

Customer Information

Name:

Department:

University or Company:

Street:

City: State: Zip:

Country: E-mail:

Phone: ext: Fax:

Shipping Address (if different from above address):

Would you like us to contact you before you send the equipment? /

Equipment to be sent for service

Model Number: 1. 2. 3. 4.

Serial Number: 1. 2. 3. 4.

Description of Problem:

Estimated Time of Arrival: / / (mm/dd/yyyy)