IBT Service Form

Emergency Request   GH NC HO Generic

Ordered from: Ship to:  Integrated Barcode Technology   9693 Gerwig Lane Suite J   Columbia, MD 21046   Att: Order entry Ship to will be the same as bill to Purchase Order Number: Bill to address:

Terms: Net 30 Credit Card:

Expiration Date Month: 1 2 3 4 5 6 7 8 9 10 11 12   Year: ex. 01, 02....

Carrier/freight: UPS UPS 1 day UPS 2 day UPS 3 day FedX Common Carrier Product to be serviced Serial number Qty Suspected problem Maintenance contact person Telephone number Product sent to IBT on what date? ex. mm/dd/yyyy Turnaround time requested 48 hr 72hr 1 week 2 week standard * if parts are in stock Other