SRA Form

Service Request Authorization Form

*Do not return compressed gas cylinders with repair*
Each instrument sent in for repair must be accompanied by this Service Request Authorization Form. To expedite repair orders, please include a “Not to exceed” dollar amount. Method of payment for all non-warranty repairs to be made by credit card or check prior to instrument return. Failure to provide complete information may delay completion of the repair order
Full Name:*

First NameLast Name
Company*
Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Shipping Address if different than billing

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail:*
Instrument / Accessory*
Detailed Description of Problem*
Return To: TG Technical Services 613 SW 3rd. Street - Suite B, Lees Summit, MO 64063
Should be Empty:

Service Request Authorization Form