RMA Request Form
Acura Embedded Systems Inc. AES-R23
Customer Information
Company Name
*
Contact Name
*
First Name
Last Name
Email
*
example@example.com
Alternative Email Address
example@example.com
Contact Position/Department
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Alternative Phone Number (Optional)
Please enter a valid phone number.
Format: (000) 000-0000.
Business Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Return Address Same as Billing Address?
Yes
No
Return Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Product Information
Product Name
*
Name of the product(s), i.e PowerBrick Mini, RoughNeck 15.6, or available Model number
Quantity Affected
Models *(Price of Repair Determined Upon Warranty Check + Parts)
prev
next
( X )
RoughNeck
Fully Sealed Panel PC
$
Free
Screen Size
15.6"
15"
22"
Quantity
1
2
3
4
5
6
7
8
9
10
Mercury
Front Sealed Panel PC
$
Free
Screen Size
15.6"
22"
Quantity
1
2
3
4
5
6
7
8
9
10
AcuPanel
$
Free
Screen Size
10" 4:3
10" 16:9
12"
15" 4:3
15" 16:9
17"
19" 4:3
19" 16:9
22"
Quantity
1
2
3
4
5
6
7
8
9
10
AcuBrite (Monitor)
$
Free
Screen Size
10" 4:3
10" 16:9
12" 4:3
12" 16:9
15" 4:3
15" 16:9
19"
22"
Quantity
1
2
3
4
5
6
7
8
9
10
PowerBrick
$
Free
Type
Quantity
PowerBrick DV
1
2
3
4
5
6
7
8
9
10
PowerBrick Slim
1
2
3
4
5
6
7
8
9
10
PowerBrick Mini
1
2
3
4
5
6
7
8
9
10
PowerBrick Ultra
1
2
3
4
5
6
7
8
9
10
Tablets
$
Free
Type
Quantity
Getac A140
1
2
3
4
5
6
7
8
9
10
Getac F110
1
2
3
4
5
6
7
8
9
10
Cameras
$
Free
Type
Quantity
EagleEye EX Camera
1
2
3
4
5
6
7
8
9
10
WatchDog Ex Mini Camera
1
2
3
4
5
6
7
8
9
10
Serial Number
*
Please create a new RMA for each system.
0/1
Invoice Date
-
Month
-
Day
Year
Date
PO Number if Applicable
Purchased From
*
Please Select
Acura Embedded Systems Inc.
Acura Embedded Certified Distributor
3rd Party
Condition of Return
*
Un-used/un-opened
New/ Like New
Good
Slightly Used
Used
Damaged
Other
Type of Issue
*
Screen Issue
Memory Issue
Storage/Drive Issue
OS Issue
I/O Issue
Network Issue
Embedded Board Issue
Damage
Other
Details
*
Please provide as much information as possible
Please upload any files or images that help explain the issue
Browse Files
Drag and drop files here
Choose a file
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of
Accessories Shipping with System
Please list all accessories that you will be shipping with the system so we can ensure that they are all sent back to you.
Form Submission Date
*
-
Month
-
Day
Year
Date
Please verify that you are human
*
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