Specifications

Remote Automation Solutions
Repair Authorization Form
( Providing this information will permit Remote Automation Solutions to effectively and efficiently process your return.
Completion is required to receive optimal lead time. Lack of information may result in increased lead times.)
Form GBU 13.01 Rev. F 11/25/08
Date ____________ RA # _________________ SH Line No. _________
Standard Repair Practice is as follows: Variations to
this is practice may be requested in the “Special
Requests” section.
• Evaluate / Test / Verify Discrepancy/Repair/Replace
Please be aware of the Non warranty standard
charge:
• There is a $100 minimum evaluation charge.
The party sending in material is responsible to ensure that the materials returned are clean to safe levels,
defined and/or determined by applicable federal, state and /or local law regulations or codes. Such party agrees
to indemnify Remote Automation Solutions harmless to any liability or damage which Remote Automation Solutions
may incur or suffer due to such party’s failure to so act.
Part I Please complete the following information for single unit or multiple unit returns
Address No. _____________ Address No. ____________
Bill to : _____________________________________
____________________________________________
____________________________________________
Ship to: ___________________________________
____________________________________________
____________________________________________
Purchase Order: _________________________ Contact Name: _____________________________
Phone: _____________________ Fax: ______________________ E-Mail: ______________________
Part II Please complete Parts II & III for each unit returned
Model No./Part No. _________________________ Description: __________________________________
Range/Calibration: _________________________ S/N: ___________________________________
Reason for return : Failure Upgrade Verify Operation Other __________________________
1. Describe the conditions of the failure (Frequency/Intermittent, Physical Damage, Environmental Conditions,
Communication, CPU watchdog, etc.) ___________________ (Attach a separate sheet if necessary)
2. Comm. interface used: Standalone RS-485 Ethernet Modem (PLM (2W or 4W) or SNW)
Other: ______________________________________
3. What is the Firmware revision?_______________ What is the Software & version? _______________
Part III If checking “replaced” for any question below, check an alternate option if replacement is not
available
A. If product is deemed not repairable would you like your product: returned replaced scrapped?
B. If Remote Automation Solutions is unable to verify the discrepancy, would you like the product: returned
replaced *see below?
* Continue investigating by contacting the customer to learn more about the problem experienced? The person to
contact that has the most knowledge of the problem is: __________________ phone _________________
If we are unable to contact this person the backup person is:________________ phone _________________
Special Requests:
__________________________________________________________________________________________
Ship prepaid to: Remote Automation Solutions, Repair Dept., 1100 Buckingham Street, Watertown, CT 06795
Phone: [phone] Fax: [phone]