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)

    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*:

    Different Billing Address?

    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: