Appointment Request Form

User Manual: Appointment Request Form

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Appointment Request Form
910 East Orangefair Lane, Anaheim, CA 92801
714-992-6990 714-992-0471, Fax
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:
Company Name: Today’s Date:
Dates Available:
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:
___ Current Supplier to Anaheim Automation
___ Prospective Supplier to Anaheim Automation
Customer Classification:
___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
Current Customer:
___Need to Purchase Product as soon as possible
___Return/Repair/Replacement, with a
___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: Expiration Date:
___COD: Check ___Net 30 Account
___Taxable ___Resale - Form on File
Shipping: ___UPS or ___ FedEx: ___Ground __1-Day __ 2-Day __3-Day ___Will Call
If different than the Ship To information, provide Billing Address:
Print Form
Submit by Email

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