Visionix Equipment Replacement Agreement

Visionix Equipment Replacement Agreement
Support Advisors Email:
Date Created

MonthDayYear
Date
Hour MinutesAM/PM Option
Account Name:
Account Number:
Contact Name:

First NameLast Name
Phone Number:
Customer Email:
Case Number:
Device Model:
Device:
Confirm Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I Name* customer name authorize Visionix USA to ship me a replacement device. As such I understand that my device becomes the property of Visionix on the arrival and installation of this replacement device. I understand that I must return my old device to Visionix. I further understand that my failure to return to Visionix within 30 days will result in my being invoiced for the full new list price of said device. My signature below is both acknowledgment and agreement to these terms.
Agree with Terms?*

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Authorized Signer Required
Authorized Signer*

Clear
Please Authorize here
Date Authorized*

MonthDayYear
Date
Hour MinutesAM/PM Option
Current Model SN
If Accepted, a signed copy will be sent to the Support Advisors and yourself.
Should be Empty: