Testing Request Form
EC Service Logo

Please Send Testing Materials To:
EC Service
915 South Frontage Rd.
Centerville, UT 84014-3211

Testing Request Form

* denotes required information.

Request for Quotation: *Date of Request:  
*Company Name:   
Invoice

*Address: 

*City: 

*State:  

*Zip Code: 

Report

same as invoice

Address: 

City: 

State:  

Zip Code: 

 

*Contact Name:  Contact Name: 
*Telephone:  Telephone: 
*Email:  Email: 

  

Sample Information

Sample Description Model # Serial # Quantity

 

Please Send with Your Samples:

 Operator/Owner's manual(s) or IFU and/or

 Specific set-up instructions for testing (please email to info@ec-service.net)

 

Please Complete for EC Service Testing *required

Sample Description Test Description Test Standard

 

Results

*Date results requested by: 

Do you require the RAW DATA (MED. DEV Directive)?       

 

After Test is Complete

What do you want us to do with test items? Please select the options that apply.

 

 I authorize EC Service to charge for return freight 

Authorized Signature:        Date: 

 

Client Confirmation: We confirm that the above information is complete and understand that the performance of the services described are governed by EC Service General Conditions of Service available upon request at quality@ec-service.net

*Authorized Signature:        *Date: 

Disclosure: By typing my name I herby authorize this information for use by EC Service as indicated and directed in the form.

Pricing applies to testing only. Prices are subject to change without notice. Price quotations are valid for up to 90 days. Upon acceptance of quote please send PO or email authorization to the attention of Randy Cunningham ( randall@ec-service.net)

 


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