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REQUEST FOR A RETURN AUTHORIZATION NUMBER (RAN)
Complete all items on this form and submit the information. We will respond with a return authorization number.
 Date: 05/29/17
Contact person at your facility:
Phone number:
Fax number:
Email address:
Do you want a rental? Yes  No  
Model number of your unit:
Serial number of your unit:
 
Rental products are available to the customer at a charge. Customer pays shipping costs, both ways. This program is for customers who require their systems to be up and running and cannot be out of operation during normal repair or calibration of a Rudolph product. Billing and shipping information, i.e. a purchase order, or purchasing card, etc., prior to shipment of a rental is required. The serial number of your unit is necessary to ship a rental.
 
Purchase Order number:
Bill to address:
Ship to address:
 
DO NOT SEND IN EQUIPMENT UNTIL YOU RECEIVE A RAN
Payment Method: Visa MasterCard American Express P.O. 
P.O.Number:
Name on Card:
Credit Card Number:
Expiration Date:
CVV Number: (3 or 4 digit number on back of card)
Bank Phone Number: (optional)
 
 

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