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

www.anaheimautomation.com

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:

___ 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

RMA#__________________________________

___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:

Established

___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:

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