RADCAL  DYNALYZER  SERVICE  REQUEST  FORM

Purchase Order #:

( Amount according to Radcal Price List )

BILL  TO:
Mr.  Ms  Dr.
First Name	Last Name
Company/Hospital	Department
Address	City
State/County	Zip/Postal Code
Country
Phone	Fax
Email

SHIP  TO:
Click HERE if same as "Bill To"	Mr.  Ms  Dr.
First Name	Last Name
Company/Hospital	Department
Address	City
State/County	Zip/Postal Code
Country
Phone	Fax
Email

Shipping company preferred and method of shipment:
Providing the following data about the equipment and whom we may contact for additional technical details will greatly assist Radcal in servicing your instrument.
Technical Contact
Phone    Email
Instrument Description
Serial Number

Normally we test, repair if necessary, and calibrate each instrument we receive.  Please check the appropriate box.
Repair and Calibrate	Calibrate Only	Call if repairs are requested	Upgrade

Please note any functions where you have had problems.
Function	No Output	Intermittent	Noisy	Expected	Actual
Anode Voltage   ( Dynalyzer, HV-1 )
Cathode Voltage   ( Dynalyzer, HV-1 )
Anode mA   ( Dynalyzer only )
Filament Current   ( Dynalyzer only )

Notes: