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    Return Materials Authorization Form

Thank you for using our on-line RMA system. Please fill out the following form for each item of equipment being returned for service. When you submit this form, the next page will provided a printable copy of your submission.

Payment Terms: All Potomac Instruments, Inc. parts and service invoices will be restricted to one of the following:
1. Credit Card Transaction (Visa, MasterCard or American Express)
2. Payment in Full prior to shipment (CIF)
3. COD (to authorized accounts)
    Return Materials Authorization Acknowledgement


Potomac Instruments, inc.
7309 Grove Road Unit D
Frederick, MD 21704

Date: 06-23-2017    -    RMA Number

Please print a copy of this form and enclose a copy with the equipment you ship
.

Please print the RMA number on the packing carton(s). Ship to the address above. If you have any questions, please contact our service department at 301.696.5550. Please print a second copy to retain for your records.

Credit Terms: All Potomac Instruments, Inc. parts and service invoices will be restricted to one of the following:
1. Credit Card Transaction (Visa or MasterCard)
2. Payment in Full prior to shipment (CIF)
3. COD (to authorized accounts)


        About the Equipment:
Model Number:
  Serial Number:
  Warranty Claim:
        Primary Customer Contact Person: Alternate Customer Contact Person:
  Name: Name:
  Telephone: Telephone:
  FAX: FAX:
  E-mail: E-mail:
        Company Name / Station Call Letters:
        Shipping Information:
  Attention:
        Shipping Information (P.O. No., Street Address, Suite No.)
  Address 1:
  Address 2:
  City, State, Zip:
        Billing Information:
  Attention:
        Billing Information (P.O. No., Street Address, Suite No.)
  Address 1:
  Address 2:
  City, State, Zip:
        Nature of Service Requested, Symptoms Observed, Additional Information
         & Special Instructions: