65
REPAIR APPLICATION FORM
Company Name _____________________________________________________________
Company address ____________________________________________________________
_____________________________________________________________________________
Phone _____________________________________ Fax. ___________________________
Type of sensor / converter ____________________ Series No. _____________________
Type of liquid _______________________________ Interior cleaning (Y / N) ___________
Claim _______________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
We hereby confirm that there is no risk to persons or the environment due to any residual
substances contained in the device that is returned
Data _______________________________________
Company stamp ____________________________ Signature _______________________
REPAIR APPLICATION FORM