Appointment Request Form

User Manual: Appointment Request Form

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Appointment Request Form

Visitors to Anaheim Automation must have an appointment to meet with a member of the sales, marketing, purchasing or technical staff.
This policy applies to all customers, vendors and prospects. If a customer has a product in need of repair, it may be dropped off with our
receptionist or receiving clerk. Please fill out this form, and the receptionist will forward your request to the most appropriate employee.
The requestor will be notified by phone, fax, or email with the appointment confirmation within 36 hours. Thank You!
Company Information – please provide information below
Contact Name:

Title:

Company Name:

Today’s Date:

Address:

Dates Available:

City/State/Zip:

Best Time to Call:

Phone:

Ext.:

Cell:

Fax Number:

Company’s Web Site:

Email:

Briefly describe your reason for this appointment request: please check all that apply
Vendor Information:

Customer Classification:

Current Customer:

___ Current Supplier to Anaheim Automation

___User Account – Need Tech Help
___Student /Teacher (class project) Need Tech Help
___Hobbyist – Need Tech Help
___Existing OEM Customer – Need Tech Help
___Prospective OEM Customer - Need Tech Help

___Need to Purchase Product as soon as possible
___Return/Repair/Replacement, with a
RMA#__________________________________

___ Prospective Supplier to Anaheim Automation

___Return/Repair/Replacement, but do NOT have
a RMA assigned (see box below)

RMA# REQUEST (Return Materials Authorization) – please use one line for each product returned
Model Number

Description of Problem

Serial Number

Date Code

NOTE: Repairs are typically completed in approximately 10 business days.

NEW PURCHASE – use one line for each part number ordered – P.O. #____________________
Model Number

Description of Product – such as motor, driver, controller

Quantity

Req. Date

Payment and Shipping Options – please choose from options below
VISA or MasterCard Number:

Name on card:

Established
___COD: Check
___Net 30 Account
Shipping: ___UPS or ___ FedEx:
___Taxable
___Resale - Form on File
If different than the Ship To information, provide Billing Address:

___Ground __1-Day __ 2-Day __3-Day

910 East Orangefair Lane, Anaheim, CA 92801
714-992-6990
714-992-0471, Fax
www.anaheimautomation.com

Print Form

Expiration Date:

Submit by Email

___Will Call
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