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CUSTOMER INFORMATION
Customer Name*:
Address 1*:
Address 2*:
 
Tel* : - - (country code - area code - number)
Fax : - - (country code - area code - number)
E-mail Address*:
Contact Person*:
Title:
PRODUCT INFORMATION
Product Description*: 
Catalog No*.: 
Lot/Control No*.: 
Expiration Date*:
Target Value/Range: Customer Results:
Instrument Used:
INVENTORY INFORMATION
Date you received product at your warehouse? * Phoenix Invoice No.*
How many kits did you receive? * How many kits do you still have in your inventory?*
BACKGROUND INFORMATION
Describe problem/complaint (Please give as much detail as possible). *
 What corrective actions have you taken and what were the results?