REPAIR REQUEST APPLICATION FORM

**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.
1710 Hempstead Turnpike, East Meadow, NY 11554

Customer Information

Name:

Department:

University or Company:

Street:

City: State: Zip:

Country:   United States Canada Mexico E-mail:

Phone: ext: Fax:

Equipment Information of Repair Requested

Model Number: 1. 2. 3. 4.

Serial Number: 1. 2. 3. 4.

Description of Problem:

Shipping date to Narishige: / / by

* Please complete and print out this form and enclose this in the package with equipment, so we know who it is from when we receive it.

* The repair of your equipment will be expedited if you fax it to 516-794-0066.

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