First Name *

Last Name *

Email *

Phone

Company *

Job Title C-Level/General Manager Vice President Director Manager Supervisor Engineer Associate/Specialist

What best describes your company? Automation Manufacturer Consultant Contractor Distributor End User EPC / Engineering Firm OEM / Machine Builder Other Systems Integrator

Country * Anguilla Antigua and Barbuda Argentina Bahamas Barbados Belize Bermuda Bolivia Bonaire Bouvet Island Brazil British Virgin Islands Canada Cayman Islands Chile Clipperton Island Colombia Costa Rica Cuba Curaçao Dominica Dominican Republic Ecuador El Salvador Falkland Islands (Malvinas) French Guiana Greenland Grenada Guadeloupe Guatemala Guyana Haiti Honduras Jamaica Martinique Mexico Montserrat Navassa Island Nicaragua Panama Paraguay Peru Puerto Rico Saba Saint Barthélemy Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Sint Eustatius Sint Maarten South Georgia and South Sandwich Islands Suriname Trinidad and Tobago Turks and Caicos Islands U.S. Virgin Islands United States of America Uruguay Venezuela

Street *

City *

State/Province

Postal Code *

Industry * Airports Automotive Manufacturing Broadband Service Provider Broadcast & Studios Building Automation Cement, Glass, Paper Chemical Processing Commercial Real Estate Consumer Packaged Goods Manufacturing Datacenter Federal & Military Government Finance, Banking, Insurance Food & Beverage Healthcare Higher Education Hospitality Industrial Automation Products Intelligent Traffic Systems Mass Transportation Material Handling Medical Devices Metal Processing Metal Working Machinery (Tooling and Molding etc.) Military Vehicles/Weaponry Mining Oil & Gas Other Machinery Pharmaceutical Power Distribution Power Generation Retail Robotics Seaports Semiconductor Manufacturing Ships & Aircrafts Stadium & Venue State & Local Government Test & Measurement Equipment Warehousing & Logistics Water & Waste Water Wireless Carrier

Distributor products purchased from: *

Distributor PO *

Type of Return * Warranty Repair Non-Warranty Repair Incorrect Order Return Evaluation Upgrade Other

Model Number *

Serial Number *

Please describe in detail how the unit was used when in service. *

Please explain in detail reasons for failure, observations, tests performed *

Add Another Return? Yes No

Type of Return (2) Warranty Repair Non-Warranty Repair Incorrect Order Return Evaluation Upgrade Other

Model Number (2)

Serial Number (2)

Please describe in detail how the unit was used when in service (2).

Please explain in detail reasons for failure, observations, tests performed (2)

Add Another Return? Yes No

Type of Return (3) Warranty Repair Non-Warranty Repair Incorrect Order Return Evaluation Upgrade Other

Model Number (3)

Serial Number (3)

Please describe in detail how the unit was used when in service (3).

Please explain in detail reasons for failure, observations, tests performed (3)

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