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:

Credit Card Transaction (Visa, MasterCard or American Express)
Payment in Full prior to shipment (CIF)
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:

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