Part Request Form
Company Name
Street Address
City/State/Zip Code
Contact
Phone
Fax
Purchase Order Number
Call ID #
System Configuration Information:
System S/W
Version
Problem description (please describe symptoms, error messages and actions taken):
Failed part information:
Part Number:
89
Model Type
Warranty
Type of failure:
Peripherals:
Solid
DAT
Intermittent
Floptical
Revision:
System Serial #
Y
N
Voltage:
CD-ROM
110
Other________
220
Date:
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this form in its entirety!
RMA#
Closed
(as found on back panel)
Disk (MB/GB)
Memory (MB):
Date
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