Repair/Return Form

Please note: Payment for repairs is by credit card only. Unit(s) sent in for repair will be placed on hold until payment is received. An invoice will be sent to the email provided below that includes a secure link to pay by credit card.

Repairs may be sent to:

Brymill Cryogenic Systems
105 Windermere Avenue
BLDG 2B
Ellington, Connecticut 06029 USA

Please fill out the fields that apply:

(*required field entry)

Name of Institution/Company*

Contact Name*

Address*

Phone Number*

Email Address*

Item(s) to be Returned for Repair:

Note: If the unit does not have a date coded serial number, the unit will not be able to be services. If you have any questions, please call Repair department at phone number 860 724 2675.

Quantity being returned:

Cry-Ac / B-700

Cry-Ac / B-700 Serial Number

Cry-Ac / B-700 Quantity

Cry-Ac / B-700 Reason for Return

Cry-Ac-3 / B-800

Cry-Ac-3 / B-800 Serial Number

Cry-Ac-3 / B-800 Quantity

Cry-Ac-3 / B-800 Reason for Return

Cry-Baby / B-400

Cry-Baby / B-400 Serial Number

Cry-Baby / B-400 Quantity

Cry-Baby / B-400 Reason for Return

Mini Cryogun

Mini Cryogun Serial Number

Mini Cryogun Quantity

Mini Cryogun Reason for Return

Cryogun

Cryogun Serial Number

Cryogun Quantity

Cryogun Reason for Return

Withdrawal Device

Withdrawal Device Serial Number

Withdrawal Device Quantity

Withdrawal Device Reason for Return

Withdrawal Tube

Withdrawal Tube Serial Number

Withdrawal Tube Quantity

Withdrawal Tube Reason for Return

*Was anyone injured by the device being returned for repair?

No
Yes

If Yes, explain occurrence:

Please print this page before you submit. Include this form in the box with your returned item for servicing.

QF7540-1
Rev. A