Name:*

Organization/Company Name:*

Designation/Occupation:*

Division/Department:*

Address:*

Unit # / Building name:

Postal code: *

Country:

Telephone:*

Mobile phone:

Fascimile: 

Email address:*

Product category:*

-- Please select your product category -- Programmable Controllers Programmable Terminals Motion Control Communications Wireless Solutions Remote I/O IT/Software Products Sensors Safety Solutions RFID Systems 2D Code Readers Temperature Controllers Timers Counters Digital Panel Meters Switching Power Supplies Switches Relays Level Controllers Others

Product model/name:*

(eg: CS1G-CPU45H)

Lot number:

(eg: 071107K Ver.4.0)

Purchase date:

  (DD/MM/YYYY)

Route of purchase:

Failure description:

Book your appointment:

Date:   Time:

For ‘Repairable’ Conditions:

• Unit within 7 years period from manufacture date

• Spare part available

• Depend on condition of the unit

Payment Mode *:

Internet Banking Mode

Bank name: The Bank of Tokyo Mitsubishi UFJ Ltd

Bank A/C   : 104231

Cash

Cheque

Collection of Goods *:

Self-collection
Local courier
  ($17 per trip, exclusive of 7% GST)

Remarks: Content of the repair-services is subject to change at anytime, without prior notification.