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

1111 Highland Avenue, WIMR Rm B1002
Madison, WI 53705-2275
Phone: (608) 262-6320 FAX: (608) 262-5012

REQUEST FOR INSTRUMENT CALIBRATION

* Red Border Indicates Required Information

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

Reporting and Shipping Address

Physicist*:
Institution*:
Address 1*:
Address 2:

City*: State*: Zip*: Country:

Phone*: Email*:

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

Billing Information----

Billing Contact*:
Institution*:
Address 1*:
Address 2:

City*: State*: Zip*: Country:

Phone*: Email*:

Return Shipping Instructions: Your instruments will be returned to you via FedEx Std Overnite unless otherwise requested. 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:

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

Insure Package (only applies if you use your own Shipping Account) [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

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

Instrument Submitted for Calibration
Calibration Type: Model No.: Serial No.:
Calibration PointCalibration PointCalibration PointCalibration Point

Instrument Submitted for Calibration
Calibration Type: Model No.: Serial No.:
Calibration PointCalibration PointCalibration PointCalibration Point

Instrument Submitted for Calibration
Calibration Type: Model No.: Serial No.:
Calibration PointCalibration PointCalibration PointCalibration Point

Instrument Submitted for Calibration
Calibration Type: Model No.: Serial No.:
Calibration PointCalibration PointCalibration PointCalibration Point

Instrument Submitted for Calibration
Calibration Type: Model No.: Serial No.:
Calibration PointCalibration PointCalibration PointCalibration Point

Please check all that apply:

For electrometers, I authorize the UWADCL to perform minor repairs or battery replacement, which may cost up to $300
For electrometers, remove and do not replace electrometer battery if it is faulty and not required for operation
Request Barcode Report for automated Calibration Coefficient data entry into electrometer (ion chambers + well-chambers)

Comments:

Print the completed form and include with shipment [set Printing Scale to "Fit to Page Width" for best results]