Warranty registration form

Warranty Registration Form

Please fill out all the applicable fields. Fields in BOLD are required.

CUSTOMER INFORMATION

First Name:

Last Name:

Title:

Company Name:

Address:

Address 2:

City:

State/Province:

Zip/Country Code:

Country:

E-mail:

Phone:

Fax:

Model:

Serial Number:

Date Installed:

Did an Astro-Med Field Service Technician install your product?
YES NO

Did the product run properly upon installation? YES NO

Are you completely satisfied with this product? YES NO

If no, please describe how you would improve it:

Please describe your involvement with your Astro-Med product:

I use/will use Astro-Med products

I recommend the purchase of Astro-Medr products

Both

Neither

Which of the following best describes your job function?

General/Corporate Management	Manufacturing/Production
Field Service	Purchasing/Procurement
Education	Research
Electrical Maintenance	R&D Engineering
Evaluation/Quality Control	Test Engineering

We would like to notify you of free product upgrades, enhancements, and other company news. If you do not want to be contacted, please check here:

USAGE INFORMATION

What is the primary industry of your company?

Aerospace	Metals
Automotive	Mining
Education	Oil/Gas
Electronics	Power
Government	Power
Heavy Equipment	Pulp/Paper
Industrial Automation	Service
Manufacturing	Telecommunications
Medical	Other:

For what application(s) will you use your Astro-Med instrument?

Is this a new requirement or are you replacing an existing system?

                         New requirement
                         Replacing existing system

If this is replacing an existing system, what system is it replacing?

Do you plan to review data collected with your Astro-Med system with a PC?
YES NO

If yes, what software do you plan to use? (check all that apply)

Excel	Mathcad
FlexPro	LAbVIEW
MATLAB	DADiSP
Other:

OTHER INFORMATION

Where did you hear about us ? (check all that apply)

Trade Show	Mailing
Web Search	Magazine Ad
Referral	Web Ad
Other: