Br eathalyser Calibration Form

1 _____ Sydney - Head Office 128 O Riordan St, Mascot 2020 PO Box 7089, Alexandria NSW 2015 Ph: 02 8338 1555 Fax: 02 8338 1688 Perth 486 Great Eastern Hwy Ascot W A 6104 Ph: 08 9479 3866 Fax: 02 6267 8168 Brisbane 11/ 17-19 University Drive, Meadowbrook QLD 4131 Ph: 07 3200 4944 Fax: 07 3200 4955 Breathalyser Calibration Form 1. Personal/Return Delivery Details Tax Invoice Name:_____ Address: _____ Suburb: _____State: _____ Postcode: _____ Contact Name:_____ Tel: _____ Email: _____ 2. Calibration Device Type (Please Tick) PERSONAL Models (___ x Units) @ $ + GST ($ incl. GST+ includes return freight) AlcoFind AF-33C/AFM-5/DA-8000, ACS Drivesafe, Alcolizer Easy Check, Dr ger 3820, Lifeguard Alcolizer HH1/HH2/LE (___ x Units) @ $ + GST ($ incl.)

2 GST) Lion Alcoblow/SD400/500 (___ x Units) @ $ + GST ($ incl. GST) Lifeloc FC10, Dr ger 5510/6510, (___ x Units) @ $ + GST ($ incl. GST) 6810/6820, Intoximeter. AlcoQuant 6020 (___ x Units) @ $ + GST ($ incl. GST) $_____ 3. Mouthpieces Workplace Models Alcolizer HH1/HH2 (_____x Bag 100 tubes) @ $ + GST ($ incl. GST) Alcolizer LE (_____x Bag 250 tubes) @ $ + GST ($ incl. GST) Dr ger 6510/6810 (_____x Bag 25 tubes) @ $ + GST ($ incl. GST) AlcoQuant 6020 (_____ x Bag 25 tubes) @ $ + GST ($ ) $_____ 4. Freight, Postage & Handling - We will utilise Star Track Express for return of your breathalyser, unless otherwise directed by the customer.

3 Return Freight Charge (up to 2 units) @ $ + GST ($ incl. GST) Return Freight Charge (3-4 units & all PO boxes ) @ $ + GST ($ incl. GST) $_____ 5. Credit Card Details Card Type (circle): Visa | MasterCard | AMEX TOTAL $_____ inc GST Card Number: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ Expiry Date: __ __ / __ __ CVV_____ Name on Card:_____Signature: _____ NB: Breathalyser Sales and Service Pty Ltd will never share your personal or credit card details with anyone. While we aim to maintain the speedy and accurate recalibration turnaround times, there will be delays with your order should you not provide all details. Please allow 4-5 working days for return.

4 Ensure your breathalyser is appropriately packaged to minimise damage. Breathalyser Sales & Service Pty Ltd will not be liable for any damage that may occur during transit. Fees subject to change without notice. Check for more information. Freight included for Personal Breathalyser devices only. Comments: _____ _____ _____ Send breathalyser, with this form, to your nearest service location (see below)