ADCL Order Form

University of Wisconsin
Medical Radiation Research Center
Accredited Dosimetry Calibration Laboratory (ADCL)

1111 Highland Avenue, WIMR Rm B1002
Madison, WI 53705-2275
Phone: (608) 262-6320

REQUEST FOR INSTRUMENT CALIBRATION

Step 1 of 2

50%

Reporting and Shipping Address

Date

MM slash DD slash YYYY

PO Number(Required)

[Valid Entries are: Your PO Number, Pending, Credit Card, or Invoice]

Physicist(Required)

Institution(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

Please provide alternate Mailing or Shipping Address information in the textbox below:

Billing Information

Billing Contact:(Required)

First Last

Institution(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

Return Shipping Instructions: Your instruments will be returned to you via FedEx Std Overnite unless otherwise requested. Please indicate the amount of insurance coverage desired. If you wish to use an alternate mode of transportation, please fill in the appropriate information below. The cost of shipping, handling and insurance will be prepaid and added to your invoice.

International Customers: If you are shipping from outside the USA, please call in advance to discuss international shipping requirements. All return shipments to international destinations require the use of your shipping account. The UWRCL will not prepay customs and duty charges.

Alternate Shipping Method

If "Other" is chosen, please enter the desired service

To use your own Shipping Account, enter your Account Number here

Insure Package

[USD]

Terms of Service: The University of Wisconsin is not liable for any damage or loss of the instruments unless said damage or loss is due to negligence on the part of the laboratory personnel.

Note: You must accept the Terms of Service in order to fill out the rest of the form.

Accept the Terms of Service(Required)

I agree to the Terms of Service

Instrument Submitted for Calibration

To enter Electrometer and/or Survey Meter scales, manually type in the Scale Name(s) in the Scale Name text box(es) [One per box]

Calibration Type

Model No.

Serial No.

Calibration Point

Scale Name

Please select one of the following checkboxes:(Required)

I authorize the UWADCL to perform minor electrometer repairs or battery replacement, which may cost up to $500. If the cost exceeds $500 we will contact you prior to performing any repairs.

Please contact us before performing any electrometer repairs or battery replacement.

Please check the box below if applicable:

Remove and do not replace electrometer battery if it is faulty and not required for operation.

Add a second instrument?

Yes

Calibration Type

Model No.

Serial No.

Calibration Point

Scale Name

Please select one of the following checkboxes:(Required)

I authorize the UWADCL to perform minor electrometer repairs or battery replacement, which may cost up to $500. If the cost exceeds $500 we will contact you prior to performing any repairs.

Please contact us before performing any electrometer repairs or battery replacement.

Please check the box below if applicable:

Remove and do not replace electrometer battery if it is faulty and not required for operation.

Calibration Point

Scale Name

Add a third instrument?

Yes

Calibration Type

Model No.

Serial No.

Calibration Point

Scale Name

Please select one of the following checkboxes:(Required)

I authorize the UWADCL to perform minor electrometer repairs or battery replacement, which may cost up to $500. If the cost exceeds $500 we will contact you prior to performing any repairs.

Please contact us before performing any electrometer repairs or battery replacement.

Please check the box below if applicable:

Remove and do not replace electrometer battery if it is faulty and not required for operation.

Calibration Point

Scale Name

Add a fourth instrument?

Yes

Calibration Type

Model No.

Serial No.

Calibration Point

Scale Name

Please select one of the following checkboxes:(Required)

I authorize the UWADCL to perform minor electrometer repairs or battery replacement, which may cost up to $500. If the cost exceeds $500 we will contact you prior to performing any repairs.

Please contact us before performing any electrometer repairs or battery replacement.

Please check the box below if applicable:

Remove and do not replace electrometer battery if it is faulty and not required for operation.

Calibration Point

Scale Name

Add a fifth instrument?

Yes

Calibration Type

Model No.

Serial No.

Calibration Point

Scale Name

Please select one of the following checkboxes:(Required)

I authorize the UWADCL to perform minor electrometer repairs or battery replacement, which may cost up to $500. If the cost exceeds $500 we will contact you prior to performing any repairs.

Please contact us before performing any electrometer repairs or battery replacement.

Please check the box below if applicable:

Remove and do not replace electrometer battery if it is faulty and not required for operation.

Calibration Point

Scale Name

Comments

Print the completed form and include with shipment.

Name

This field is for validation purposes and should be left unchanged.

ADCL Order Form

University of Wisconsin
Medical Radiation Research Center
Accredited Dosimetry Calibration Laboratory (ADCL)

1111 Highland Avenue, WIMR Rm B1002
Madison, WI 53705-2275
Phone: (608) 262-6320

REQUEST FOR INSTRUMENT CALIBRATION

Reporting and Shipping Address

Billing Information

Instrument Submitted for Calibration

Contact Us

UWMRRC

University of Wisconsin Medical Radiation Research Center Accredited Dosimetry Calibration Laboratory (ADCL)

1111 Highland Avenue, WIMR Rm B1002 Madison, WI 53705-2275 Phone: (608) 262-6320

REQUEST FOR INSTRUMENT CALIBRATION

Reporting and Shipping Address

Billing Information

Instrument Submitted for Calibration

Contact Us

UWMRRC

University of Wisconsin
Medical Radiation Research Center
Accredited Dosimetry Calibration Laboratory (ADCL)

1111 Highland Avenue, WIMR Rm B1002
Madison, WI 53705-2275
Phone: (608) 262-6320