On Site Service Request Form

Requested Service/Calibration Date:*

Bill To:

Where is your billing address?*

U.S.
International

U.S. Billing Address*

Street Address Address Line 2 City State ZIP Code

International Billing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Job Site:

Where is your job site?*

U.S.
International

U.S. Job Site Address*

Same as billing address above

Street Address Address Line 2 City State ZIP Code

International Job Site Address*

Same as previous

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Payment*

Purchase Order #
Credit Card (Upon completion of work)

Purchase Order #*

Equipment List

Manufacturer	Model #	Asset ID/Serial #	Capacity	Type of Equipment	Description of Issue	Calibration Method : Standard or Accredited ( Accredited = ISO 17025; within our scope)	Calibration Frequency	Test Procedure Used	Test Standard Used	Scope of Service	Date Format - Exact or EOM *All equipment must have the same date format

Note: Estimated uncertainty shall be provided on each Accredited Certificate. Approved by: Paul Claugherty, Technical Manager, Kennedy Scales Inc.

Additional Notes

Decontamination: Equipment has been used with Hazardous materials?*

Yes
No

Note: If the equipment has been used with Hazardous Materials, it must be cleaned to deactivate and remove the hazardous materials. By printing your name below and submitting this completed form, you are hereby certifying that the equipment has met this requirement. You also certify that you are the equipment owner / you are authorized to act on behalf of the equipment owner, and have decontaminated the referenced unit and tested it for radiation level hazard and potential hazard(s) from bio-hazardous materials and/or chemicals.

In order to ensure the adequate protection of our technicians, Kennedy Scales, Inc. requires our customers to declare the types of substances that have been in contact with products(s) you are returning for service/repair. As part of the service agreement, you are responsible for the decontamination of your product prior to shipping.

Has this equipment been used with dangerous, poisonous, or radioactive materials?

No
Yes

Can this equipment be handled and disassembled without risk?

No
Yes

If you need assistance with decontamination instructions please consult the product manufacturer or Kennedy Scales, Inc.

Name*

First Last

Company Information

Bill To:

Job Site:

Please print form for your records before submitting.