MSD Biomedical Service Estimate Rapid Form

No service will begin until this form is signed and returned to our Service Center

Bill to:

Ship To:

Account Name:

Street Address:

City:

State:

Zip / Postal Code:

Contact Person:

Phone:

Fax:

Email:

Medical And Science Depot
33 Market Point Drive
Greenville, SC 29607
Phone: 704-572-7300
Fax: 980-500-0039

Mfg:

Date:

Model No.

S/N:

Reason for Service:

Condition:

Good

Average

Poor

Accessories:

List

Item #

Qty

MFG

Part #

Description

Cost Ea

Extra Cost

TAX not include in EST:

Total:

Service Action Proposed:

Service Technician:

Warranty:

This service estimate reflects our best recommendation for returning the equipment listed on this form to proper working condition. Due to the complexity of this equipment, discovery ofunforseen problems can occur and additional charges may apply. If additional problems are found and the costs do not exceed $50, those costs will be automatically added to the total. If the costs are greater than $50, a new estimate will be provided to you with those costs included. All applicable state sales tax will be added to the final total amount quoted at the time of invoicing. In the event that you elect not to have the equipment serviced according to this estimate or if the equipment is left at our service center without ant notification from you within 7 days, the equipment will be returned to you, unrepaired and a minimum service fee of$100 will be invoiced to you to cover the equipment evaluation and return shipping costs.

Approved:

Yes

Total Cost:

PO# :

Approver Name:

Signature

Date

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MSD Biomedical Service Estimate Rapid Form

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