Your Contact Details
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Your First Name |
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Your Last Name |
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Your Email Address |
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Your Phone Number |
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Your Office and Business Unit: |
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Customer Details
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Company Name |
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Customer Title |
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Customer First Name |
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Customer Last Name |
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Customer Contact Phone |
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Customer Address Line 1 |
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Customer Address Line 2 |
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Building/Department |
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Customer City |
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Customer Country |
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Customer State/Province |
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Customer ZIP/Postal Code |
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Customer Email Address |
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Pipette Lead Details
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Brand:
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Thermo Scientific Model:
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If Thermo Scientific model is other, please explain: |
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Serial Number: |
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Type of Pipette: |
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Number of channel(s): |
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Defect on current pipette: |
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Price the repair would be quoted: |
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Comments: (Please include any additional customer information, application, etc) |
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Please check this box if the customer must be contacted within 1 working day. |
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