Service Request Form (click here for printable PDF version)

Fill out the following information (bold fields are mandatory) and click 'Submit'.

1) INVOICE/BILL TO ADDRESS 2)SHIP TO/RETURN ADDRESS
End User Dealer
Company:
Address 1:
Address 2:
City:
State/Province:
Zip Code:
End User Dealer
Company:
Address 1:
Address 2:
City:
State/Province:
Zip Code:
   
3)CONTACT/END USER INFORMATION 4)PURCHASING INFORMATION
Contact Name:
Phone #:
Fax #:
Email Address:
Verify Email:
Contact Name:
Phone #:
Fax #:
Email Address:
Verify Email:
   
5)REPAIR INFORMATION  
Model Number:
Serial Number:
Model Number:
Serial Number:
Problem:
Check Yes for Warranty Claim: Yes No
   

8) EXPEDITED SERVICE ON PRE-APPROVED REPAIRS: Microscopes recieved with repair approval purchase
orders (hardcopy) are sent directly to a qualified service technician with no delay for repair cost approval.

9) ACCU-SCOPE is authorized to complete any repair up to and including the amount indicated below.
(fill in pre-approved amount)

Amount up to $:
Purchase Order Number:
Authorization:
Name:
Date: