LABpro Biomedical Inc - Pipette Service Request Form

LABpro Service Request Form

NOTE: All pipettes / equipment MUST be decontaminated before shipping to LABpro Biomedical Inc.

LABpro BIOMEDICAL INC.
LABpro Shipping Address:	LABpro Biomedical Inc. 241 Consortium Court London, Ontario Canada, N6E 2S8
CUSTOMER INFORMATION
Account Name:*
Contact Name 1:*
Address 1:*
Contact Name 2:
Address 2:
City, Province, Postal Code:
Phone Number:*
Email:*
PAYMENT INFORMATION
P.O.#:
Other:
NOTE: Please DO NOT include any credit card information on this form.
PIPETTE & SERVICE INFORMATION
Number of Single-Channel Pipettes:
Number of Multi-Channel Pipettes:
Level of Service:*	See Features & Price List
Next Calibration Due Date:*
Pipette Tips Enclosed for Each Pipette:	Please include some tips with each pipette you send. For electronic pipettes, please send power supplies / chargers.
Calibrate to Manufacturer's Specifications:
Copy of Specifications Provided:
Provide parts estimate if cost exceeds: ($)
Parts Estimate per:
Notes:
SHIPPING INFORMATION
Shipping Method:
Other Shipping Method:
Payment Method:
Account Number:
STATEMENT OF DECONTAMINATION
Date:*
Name (print):*
LABpro Biomedical requires all pipettes to be appropriately decontaminated for all biohazardous/radioactive material prior to shipment in accordance with manufacturers recommendations. By selecting 'Yes' in the box below you are agreeing to the above statement. By selecting 'Not Required' you are agreeing that the pipettes have not been in contact with any biohazardous or radioactive material.
Pipettes appropriately decontaminated for all biohazardous/radioactive material prior to shipment?*
Security Code:*	Reload Image
NOTE: A copy of the request form will be sent to the email address you entered in the form. Please print the form sent to your email and enclose it with your shipment after you click 'Submit'.

LABpro Service Request Form

LABpro BIOMEDICAL INC.

CUSTOMER INFORMATION

PAYMENT INFORMATION

PIPETTE & SERVICE INFORMATION

SHIPPING INFORMATION

STATEMENT OF DECONTAMINATION