| Teledyne e2v

Returns Material Authorisation Form

Contact Information

Company Name *

Contact Name *

Email Address *

Phone Number *

Mobile Number

Country *

End User Address *

Returnee Address *

Product Originally Purchased From *

Return Information

Order Number *

Quantity *

Serial Number *

Hours Of Operation *

Date Purchased *

Date Product Received *

Date Product First Tested *

Date Product Placed In Operation *

Date Of Product Failure *

Returned Product Name And Description *

Make, Model And Description Of Equipment *

Description Of Failure *

Your Reference For Return *

When Did You First Note Problem *

At incoming quality control

At first connection

During operation in the field

Upgrade request

Additional Return Information

Attachment

Imaging Device

Temperature

Numerical Aperture

Integrated Time

Focal Length

Camera Gain

Synchro Mode

Camera Over Stressed

Light Used In Operation

Visible

Infrared

UV

Verification

Verification *

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