HP 120A - Page 7

FROM:
NAME:
COMPANY:
ADDRESS:
DATE :
Person to contact for further information;
NAME:
TITLE;
COMPANY:
ADDRESS: •
To process your claim quickly please enter the information indicated below:
1) TUBE SERIAL NO. :
2)* ORIGINAL TU BE REPLACEMENT TUBE
3) ORIGINAL HEWLETT-PACKARD PURCHASE ORDER NO.
4) DATE PURCHASED:
5) PURCHASED FROM: _
6) COMPLAINT: (Please describe nature of trouble)
7) OPERATING CONDITIONS: (Please describe conditions prior to and at time of failure)
SIGNATURE:
♦ Check one.