PIPETMAN® Easy Check Service Order Form
Gilson Account Number:
Contact Information (in case there are questions regarding your order)
If you do not have a Gilson Account Number please call
Technical Support at (800-445-7661 x 6367)
*for orders of 10
pipettes or more
Name:
Phone:
Fax:
Email:
Billing Address
Company:
Shipping Address: (no P.O. Boxes)
Purchasing Contact Name:
Company:
Address:
Address:
City:
State:
Zip Code:
Calibration Certificates
Go Green! I would like to receive my pipette calibration
certificates as electronic files only. [ ] Yes [ ] No
Personal Labels
[ ] I would like my personal labels removed from my pipette(s).
Repairs (required)
Please contact me with a service estimate before replacing parts
that are not covered in the service program, see below for details.
[ ] Yes (may delay turnaround) [ ] No
City:
[ ] Same as Billing
State:
Zip Code:
Select Service Interval
[ ] 3 Months [ ] 6 Months [ ] Annually [ ] Other ________
Pipette Failures (required)
If my pipette(s) fail the Easy Check Service, please enroll my
pipette(s) in Level 1 PIPETMAN Service and Calibration. (Level 1
service collects two weighings at the low volume and two
weighings at the high volume. It also includes repair, adjustment,
a calibration label, and detailed calibration certificate.)
[ ] Yes [ ] Please call me
Select a Service Type:
PIPETMAN Easy Check: This service type provides you with the opportunity to check your pipettes’ performance in between calibration services. This pipette service includes internal and external cleaning, visual and functional inspection, leak test, gravimetric check, service label and a detailed report. Most brands of single channel pipettes will also receive free replacement of the seal and o-ring (where applicable)
and a free tip holder if evaluation shows it needs to be replaced, all other parts are extra.
Service Type
List Price
Easy Check Single Channel
$25
Easy Check Multi-Channel (One Channel, leak test all)
$33
QTY
Special Instructions (may delay turnaround):
Ship in a secure package by an insurable carrier to: Gilson Service Center | 3101 Laura Lane, Ste 100 | Middleton, WI 53562
Payment Information
P.O. Number:
Shipping Collect Account Number:
P.O. Amount:
Promo Code/Quote Number:
Credit Card Payment:
Credit Card Type:
[ ] VISA
[ ] M/C
[ ] AmEx
Name on Card:
Credit Card Number:
Expiration Date:
CVV Code:
I certify that these pipettes are fully decontaminated and are free of radioactive and biohazardous materials.
Date:
Signature
Terms: Net 30 days, FOB Middleton, WI. Freight charges are prepaid and added to invoice.
Shipping Method: Pipettes are returned by UPS Second Day Air with charges prepaid and added to invoice
unless Gilson is advised otherwise.
Turnaround: Approximately 2 business days in Gilson Service Center.
ISO 17025 Pipette Calibration Service: ISO accredited service is compliant with ISO/IEC 17025:2005.
For service information go to: www.gilson.com
phone: 800-445-7661 | fax: 608-821-4402
FORM-1090 Rev 05