Online Asset Recovery Form

Please use CAPITAL letters only. All the field with * must be fill in to complete your application.

1. Requesters Details

Company/Carrier Name: *
Address:*
Suburb:* State: * Post Code: *
Contact Name: *
E-Mail: * Tel No: * Fax No:

2. Equipment to be collected

Manufacturer Of Equipment:   If other please Specify:  

Model: * Serial Number: * Estimated Weight:Kg

3. Location of Equipment

Site Contact  First name: * Last Name: *
Address: *
Suburb: * State: * Post Code: *
Tel No: * Fax No: Mobile No:

4. Return Address

Returns to:  First name: * Last Name: *
Address: *
Suburb: * State: * Post Code: *
Tele No: * Fax No: Mobile No:

5. Additional Units at the same Location

Manufacturer Of Equipment:   If other please Specify:  

Model:  Serial Number:  Estimated Weight:Kg

6. Store and Forward

0-5Kg Box

No of days: x $5/day

 Or The Number of boxes before shipping
5-10 Kg Box

No of days: x $10/day

 Or The Number of boxes before shipping

7. Payment Terms *

On Account: Please Specify Account number:
Purchase Order: Please Specify PO number:
Credit Card Type: Amex Bankcard MasterCard VISA
        Card Holder's Name: Amex 4 Digit No:

        Credit Card Number: Expiry Date:

 

Please verify all information before you press the submit button below.

A Quote/Confirmation will be forwarded to you to confirm this request.