Mail In Repair/Calibration Service Authorization Form

Please print this form and fill in all the fields listed below, so we can process your mail service order.

Important: In order to process your repair/calibration the following must be filled out and included with your units.

Company Name:_____________________________________________________   P.O.Number______________

Contact Name:________________________________________________________________________________

Street Address:_________________________________________________ Room:_________  Bldg:___________

City:_______________________________________________ State:_____________________ Zip:____________

Phone:__________________ Ext:_______ Fax:_________________ Email:________________________________

Work Authorized By:____________________________________________________________________________

Pipette Services - Please check the level of service

Non GLP/GMP - Level 1 _______  GLP/GMP - Level 2_________ GLP/GMP - Level 3___________

Return Method of Shipment:  Standard Ground______  2nd Day Service______ Overnight______
(Return Shipping charges are prepaid by PCR, Inc. and will be added to your invoice.)

Bill To Address:

Bill To:________________________________________________________________  Dept: Accounts Payable

Street Address:______________________________________________ Room:_________  Bldg:___________

City:_______________________________________________ State:__________________ Zip:____________

Declaration of Decontamination
We certify that these instruments have been carefully cleaned and decontaminated and pose no danger through bacteriological,             
 virological, chemical or radioactive contamination. We are aware that we may be held liable for any damages caused by contaminated  

Name (Signature): ____________________________________________________________________________________________

Pipette Calibration & Repair, Inc. (PCR)
The Pipette Care People          1-(866)-450-3990