INSTRUMENT RETURN FORM

ACCOUNT NAME : INSTRUMENT MODEL :

INSTRUMENT SERIAL No. :

ADDRESS : PNEUMATIC UNIT SERIAL No. :

SAMPLE LOADER SERIAL No. :

MCP SERIAL No. :

CONTACT PERSON : BARCODE READER SERIAL No.:

PHONE NO. : XT-1800i / XT-2000i - PIM :

FAX NO. : C P U SERIAL No. :

MONITOR SERIAL No. :

KEYBOARD SERIAL No. :

MOUSE SERIAL No. :

EASYACCESS KEY : PRINTER MODEL :

EASYACCESS S.NO : PRINTER SERIAL No. :

OPERATING SYSTEM : Win 7 Pro Win 8 UPS MODEL :

OS PRODUCT KEY : UPS SERIAL No. :

UNINSTALLED BY :

UNINSTALLATION DATE:

INSTRUMENT STATUS : Sold RR Demo Evaluation CPRR

DATA UPDATED ON : MySAP CRM

CUSTOMER APPROVAL, PT KRISTALAB SURYA MEDIKA,

ENG-06-F02