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:
E-mail*: E-mail:
Company Name / Station Call Letters:
Shipping Information:
Shipping Information (P.O. No., Street Address, Suite No.)
Address 1*:
Address 2:
City, State, Zip*:
Different Billing Address?
Billing Information:
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: