subject_line
Return Material Authorization (RMA) Form
Type of Return
(check all that apply):
*
Chemical
Equipment
Is the equipment damaged/defective?:
*
Yes
No
***CONTACT NGES FOR WARRANTY REPAIR***
Has the product been opened or used?:
*
Yes
No
***RETURN AUTHORIZATION WILL NOT BE GRANTED FOR OPENED CONTAINER PRODUCTS (INCLUDING PARTIAL CASES)***
Is the chemistry over 30 days from delivery date?:
*
Yes
No
Has approval been obtained?:
*
Yes
No
Approval Authorization
(if over 30 days):
*
***APPROVAL MUST BE OBTAINED FOR CHEMICAL PRIOR TO RETURN***
PLEASE COMPLETE THE QUESTIONS BELOW AND AN APPROVAL REQUEST WILL BE GENERATED TO THE APPROVER
Sales Information
Requestor:
*
Sales Rep
Not Sales Rep
Requestor Name:
*
Requestor Email Address:
*
Sales Rep Name:
*
Sales Rep Email Address:
*
District:
*
CH101
CH102
CH103
CH104
CH105
CH107
CH108
CH109
CH110
CH111
IS111
IS112
IS113
IS114
IS115
IS116
IS117
IS118
IS119
IS120
IS121
IS122
IS123
IS125
IS126
IS127
IS128
IS129
IS131
IS133
IS134
IS135
IS136
IS141
IS142
IS143
IS144
IS145
IS146
IS147
IS148
IS149
0T110
0T112
PG101
PG102
PG104
PG105
PG106
PG107
PG109
PG120
PG122
PG123
PG124
PG126
PG130
PG131
PG132
PG133
PG134
PG135
PG136
PG140
PG142
PG143
PG146
PM101
PM102
PM103
PM104
PW101
PW102
PW103
PW104
PW105
PW106
PW107
PW108
PW109
PW110
PW111
TR101
TR102
TR104
TS101
TS102
TS103
WL101
WL102
WL103
WL104
WL105
WL106
WL107
WL108
WL121
WL123
WL124
WL125
WL126
WL127
WL128
WL141
WL142
WL143
WL144
WL145
WL146
WL147
WL182
WL183
WL184
WL185
WL186
WL187
WL188
WP1M1
WP1M2
WP1M5
Customer Name:
*
Order Type:
*
Contract
Ship & Bill
Quantity of Returned Products
(different product/pkg codes)
:
*
1. Product # . Package Code:
*
Quantity:
*
Chemical Expiration Date?:
*
+
2. Product # . Package Code:
*
Quantity:
*
Chemical Expiration Date?:
*
+
3. Product # . Package Code:
*
Quantity:
*
Chemical Expiration Date?:
*
+
4. Product # . Package Code:
*
Quantity:
*
Chemical Expiration Date?:
*
+
5. Product # . Package Code:
*
Quantity:
*
Chemical Expiration Date?:
*
+
Could this return have been prevented by any of the following?:
*
Nalco Water
Customer
Carrier
Other
Other
Has the product already been opened?:
*
Yes
No
Can this product be used at a nearby location?:
*
Yes
No
Suggested Credit Amount:
*
Customer Information
Sold-To Number:
*
Order Number:
*
Ship-To Number:
*
Customer Company Name:
*
Primary BOL Contact Name:
*
Primary BOL Contact Phone Number:
*
Primary BOL Contact Email Address
(for Bill of Lading):
*
Secondary BOL Contact Name:
Secondary BOL Contact Phone Number:
Secondary BOL Contact Email Address
(for Bill of Lading):
Pick-up Comments:
0/255 characters
Return Information
Reason for Return:
*
Change in Treatment
Damaged
Duplicate Order
Failed Trial
Lost Account
Off Spec
Wrong Package Size
Wrong Product
Wrong Quantity
Is Pick-up Address Different Than Original Delivery?:
*
Yes
No
Ship-To Number or Customer Address:
*
Customer Pick-up Hours:
*
Time Zone:
*
EST
CST
MST
PST
HST
Product Label Image:
Additional Information for Return:
0/255 characters
CHEMICAL
1. Product # . Package Code:
*
Quantity:
*
Shipping Unit of Measure:
*
Per Pound
Per Kilogram
Per Each
Per Gallon
Batch #:
Was Correct Product Shipped?:
*
Yes
No
Type of Return:
*
Full
Partial
Serial Number
(if applicable):
Is Product Hazardous?:
*
Yes
No
Unsure
Does Shipment Require Hazmat Placards?:
*
Yes
No
Placard Mailing Address:
City:
State:
Zip Code:
Add Another Product?
Yes
2. Product # . Package Code:
*
Quantity:
*
Shipping Unit of Measure:
*
Per Pound
Per Kilogram
Per Each
Per Gallon
Batch #:
Was Correct Product Shipped?:
*
Yes
No
Type of Return:
*
Full
Partial
Serial Number
(if applicable):
Is Product Hazardous?:
*
Yes
No
Unsure
Does Shipment Require Hazmat Placards?:
*
Yes
No
Placard Mailing Address:
City:
State:
Zip Code:
Add Another Product?
Yes
3. Product # . Package Code:
*
Quantity:
*
Shipping Unit of Measure:
*
Per Pound
Per Kilogram
Per Each
Per Gallon
Batch #:
Was Correct Product Shipped?:
*
Yes
No
Type of Return:
*
Full
Partial
Serial Number
(if applicable):
Is Product Hazardous?:
*
Yes
No
Unsure
Does Shipment Require Hazmat Placards?:
*
Yes
No
Placard Mailing Address:
City:
State:
Zip Code:
Add Another Product?
Yes
4. Product # . Package Code:
*
Quantity:
*
Shipping Unit of Measure:
*
Per Pound
Per Kilogram
Per Each
Per Gallon
Batch #:
Was Correct Product Shipped?:
*
Yes
No
Type of Return:
*
Full
Partial
Serial Number
(if applicable):
Is Product Hazardous?:
*
Yes
No
Unsure
Does Shipment Require Hazmat Placards?:
*
Yes
No
Placard Mailing Address:
City:
State:
Zip Code:
Add Another Product?
Yes
5. Product # . Package Code:
*
Quantity:
*
Shipping Unit of Measure:
*
Per Pound
Per Kilogram
Per Each
Per Gallon
Batch #:
Was Correct Product Shipped?:
*
Yes
No
Type of Return:
*
Full
Partial
Serial Number
(if applicable):
Is Product Hazardous?:
*
Yes
No
Unsure
Does Shipment Require Hazmat Placards?:
*
Yes
No
Placard Mailing Address:
City:
State:
Zip Code:
Add Another Product?
Yes
6. Product # . Package Code:
*
Quantity:
*
Shipping Unit of Measure:
*
Per Pound
Per Kilogram
Per Each
Per Gallon
Batch #:
Was Correct Product Shipped?:
*
Yes
No
Type of Return:
*
Full
Partial
Serial Number
(if applicable):
Is Product Hazardous?:
*
Yes
No
Unsure
Does Shipment Require Hazmat Placards?:
*
Yes
No
Placard Mailing Address:
City:
State:
Zip Code:
Add Another Product?
Yes
7. Product # . Package Code:
*
Quantity:
*
Shipping Unit of Measure:
*
Per Pound
Per Kilogram
Per Each
Per Gallon
Batch #:
Was Correct Product Shipped?:
*
Yes
No
Type of Return:
*
Full
Partial
Serial Number
(if applicable):
Is Product Hazardous?:
*
Yes
No
Unsure
Does Shipment Require Hazmat Placards?:
*
Yes
No
Placard Mailing Address:
City:
State:
Zip Code:
Add Another Product?
Yes
8. Product # . Package Code:
*
Quantity:
*
Shipping Unit of Measure:
*
Per Pound
Per Kilogram
Per Each
Per Gallon
Batch #:
Was Correct Product Shipped?:
*
Yes
No
Type of Return:
*
Full
Partial
Serial Number
(if applicable):
Is Product Hazardous?:
*
Yes
No
Unsure
Does Shipment Require Hazmat Placards?:
*
Yes
No
Placard Mailing Address:
City:
State:
Zip Code:
Add Another Product?
Yes
9. Product # . Package Code:
*
Quantity:
*
Shipping Unit of Measure:
*
Per Pound
Per Kilogram
Per Each
Per Gallon
Batch #:
Was Correct Product Shipped?:
*
Yes
No
Type of Return:
*
Full
Partial
Serial Number
(if applicable):
Is Product Hazardous?:
*
Yes
No
Unsure
Does Shipment Require Hazmat Placards?:
*
Yes
No
Placard Mailing Address:
City:
State:
Zip Code:
Add Another Product?
Yes
10. Product # . Package Code:
*
Quantity:
*
Shipping Unit of Measure:
*
Per Pound
Per Kilogram
Per Each
Per Gallon
Batch #:
Was Correct Product Shipped?:
*
Yes
No
Type of Return:
*
Full
Partial
Serial Number
(if applicable):
Is Product Hazardous?:
*
Yes
No
Unsure
Does Shipment Require Hazmat Placards?:
*
Yes
No
Placard Mailing Address:
City:
State:
Zip Code:
EQUIPMENT
1. Equipment Part Number:
*
Quantity
(each):
*
Weight:
Unit of Measure:
Kilograms
Pounds
Dimensions:
Serial Number
(if applicable):
Number of Labels Needed:
*
Add Another Product?
Yes
2. Equipment Part Number:
*
Quantity
(each):
*
Weight:
Unit of Measure:
Kilograms
Pounds
Dimensions:
Serial Number
(if applicable):
Number of Labels Needed:
*
Add Another Product?
Yes
3. Equipment Part Number:
*
Quantity
(each):
*
Weight:
Unit of Measure:
Kilograms
Pounds
Dimensions:
Serial Number
(if applicable):
Number of Labels Needed:
*
Add Another Product?
Yes
4. Equipment Part Number:
*
Quantity
(each):
*
Weight:
Unit of Measure:
Kilograms
Pounds
Dimensions:
Serial Number
(if applicable):
Number of Labels Needed:
*
Add Another Product?
Yes
5. Equipment Part Number:
*
Quantity
(each):
*
Weight:
Unit of Measure:
Kilograms
Pounds
Dimensions:
Serial Number
(if applicable):
Number of Labels Needed:
*
Order Information
Return Reason due to Off Spec Material --> Please complete a Case Management incident and provide the Case Management number below.
Click Here to Begin New Case Management
Case Management Number:
*
Do you have the original invoice number?:
*
Yes
No
Original Invoice Number:
Date Shipped:
+
Freight Paid By:
3rd Party
Customer
Nalco Water
Order Type:
Billing Arrangement
District Charge (YSD)
No Charge (YNC)
Ship & Bill
Ship & Bill SPA
SPA Number:
*
Billing Arrangement Number:
*
Billing Unit of Measure:
EA
Gallons
Lbs
KG
Customer PO Number:
Customer Release Number:
Suggested Credit Amount Method:
*
Dollars
Percentage
Suggested Credit Amount:
*
Suggested Credit Amount:
*
If restocking fee is applied, who is responsible for the cost?:
*
Nalco Water
Customer
Minimum 25% restocking fee will be applied.
Special Instructions/Comments: