| Online Surveys

Questions marked with a * are required

Dear Valued Customer,

Thank you for contacting us. Please complete all sections of the form and submit. Once reviewed, AMETEK Land will send you authorization, instructions and conditions for return. Please complete one form for each uniquely serial numbered instrument you wish to return.

Owners declaration of Health & Safety

By providing a contact name & e-mail address the owner is declaring that the equipment being returned is free from any form of contamination or hazard harmful to human health.

Name of person making declaration

I declare that the equipment being returned is free from any form of contamination or hazard harmful to human health

Yes

Customer Information (Mandatory)

Company Name

Billing Address

Shipping Address
(If different from billing)

Country

Contact Name

Contact Phone Number

Contact Email Address

Quality Manager Name

Quality Manager Email Address

Please indicate your industry type

Glass Manufacture

Mineral Processing

Power Generation

Iron & Steel

Paper, Plastics & Textiles

Hydrocarbon Processing

Speciality Metals

Equipment Reseller (EPC)

Other industrial processes please specify:

Have you heard about the benefits of a multi-year service plan for your Land instrument? 2 and 3 year service plans lock in the current year pricing plus an additional 10-15% discount. Any non-warranty repairs will also receive a 15% discount.
Please indicate your preference:

I am interested in Service Plan pricing

I am not interested in Service Plan pricing at this time

Equipment details (Mandatory)

Model

Serial Number

Reason for return including any symptoms of fault or further information.

Services Required

	Yes	No
Overhaul & calibration adjustment to manufacturer’s specification *Required: Complete Unit Diagnostics & Section A or B on Certification Worksheet*	Yes	No

ISO 17025 certification (Infrared thermometry only) Required: Complete Section C on Certification Worksheet	Yes	No

Repair	Yes	No

Parts Exchange (Discount program for New Unit Replacement)	Yes	No

Warranty Evaluation (failure within our general terms – please see user guide for details)	Yes	No

Other reason (as specified above)	Yes	No

Unit Diagnostics Worksheet (Mandatory)

	Yes	No
Is the instrument within its initial warranty period?	Yes	No

	Good	Average	Poor
How would you describe the equipment’s condition?	Good	Average	Poor

	Fully Operative	Partially Operative	Non-Operative
Does the equipment appear to be operative?	Fully Operative	Partially Operative	Non-Operative

	Yes	No
Is the output fixed or displaying excessive instability?	Yes	No

Could the equipment have been incorrectly wired, received an electrical surge or exposed to strong electromagnetic field?	Yes	No

Has the equipment been damaged?	Yes	No

If Yes:

Overheated

Water Damage

Contamination

Impact/Vibration Damage

	Yes	No
Does the equipment switches on/off, and power up normally?	Yes	No

Does the equipment have switch, terminal, connector or connection faults?	Yes	No

Is the display or output responsive to the process being measured or an electrical input (if applicable)?	Yes	No

Do you suspect the instrument is operating outside specification or giving inaccurate measurement?	Yes	No

Is the software/firmware functioning correctly?	Yes	No

Is the instrument communicating with external devices (if applicable)?	Yes	No

Are the optics clean when viewed through the lens and externally?	Yes	No

Does the equipment have damaged optical, alignment or focusing components	Yes	No

Is the equipment displaying an error message?	Yes	No

Certification Worksheet
Select only ONE option – Please complete the Certification Section A OR B for Calibration & Overhaul services OR Section C for 17025 certification.

Section A

	Re-calibrate
For Recalibration Only – Customers may select “Same as Previous” option The cost will be based on the previous service selected and will follow guidelines below	Re-calibrate

Same as Previous (Land Certs only)

Land Cert #

Section B

	Overhaul
Overhaul - includes ISO Accredited Range Calibration Certificate Customer specifies temperature range for certification – If no range is specified, the instrument operating range will be used This includes 4 hours of labor to clean, repair and calibrate the unit. Any parts and/or additional labor will be charged at the standard rate	Overhaul

	°C (Celsius)	°F (Fahrenheit)
Temperature Preference:	°C (Celsius)	°F (Fahrenheit)

Low Temperature Point:

(Required)

High Temperature Point:

(Required)

Section C

	17025 Cert
Calibration Certificate IAW ISO 17025 (Minimum 3) Customers must specify temperature points - at least 3 points are required. Additional fees will be charged for additional points. Customer will specify As Found Data, As Left Data or As Found/As Left, as defined below Measurement uncertainties are reported for each test point – this applies only to instruments specified on our ISO 17025 Scope of Accreditation Customer may specify calibration interval – due date will be blank if none are given	17025 Cert

	°C (Celsius)	°F (Fahrenheit)
Temperature Preference:	°C (Celsius)	°F (Fahrenheit)

Please specify Temperature Points:

10:

	As Found Only	As Left Only	As Found / As Left
Please Choose Only One	As Found Only	As Left Only	As Found / As Left

As Found Only: Upon receipt, the unit will be powered on to verify operation, then certified at the points specified by the customer without any lens cleaning, adjustment, repair or calibration. Please note – This option is NOT available if the unit needs repaired.
As Found/As Left: The As Found data will be collected as above, analyzed and reported. If needed, the instrument will be optimized. The As Left data will be collected and reported as well. Customers will be charged for each temperature point reported on the certificate. Should no adjustment be needed, the charge will be for the As Found data only. Please note – should the unit need to be repaired, the As Found data cannot be collected, or reported.

As Left Only: Upon receipt, the unit will be evaluated, repaired, and calibrated if necessary, as authorized by the customer. Next, the unit will be cleaned and certified at the points specified by the customer.

Calibration interval:

Months / Year(s)

	.
Please tick If you would like to hear from AMETEK Land with marketing-related communications. Please note that you can change your subscription preference at any time.	.