Rx Monitoring Services
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Order Power Quality Site Survey

Standard Service is for 10 days

If your company is new to working with Rx, please give us a call at
1-888-329-2321 Ext. 201 before ordering online.
Please note that any order placed after 3:30PM EST/EDT and on the weekend will not be processed until the following business day.

In order to fulfill your order with accuracy, all applicable fields must be entered.
Fields marked with an asterisk(*) are required.

Order Information
*Your Company:
*Ordered By (Your Name):
*Phone Number:
*Email Address:Please Double-Check your email address
PO/Contract Number:Rx does NOT accept credit cards through this form.
Client/Region:
ASM/DM:
Email Addresses For Report Distribution:
Installer Name:
Installer Phone Number:
Installer Email Address:
*New Install Or Existing System:
Site Address
Site Code or Serial Number:
Site Contact Name:
Site Contact Email:
*Site Phone Number:
*Site Name:
*Site Street Address 1:
Site Street Address 2:
*Site City:
*Site State/Other:
*Site Postal Code:
Site Country: Lookup: ISO Country Code
Ship To Address (Copy from Site Address)
As of 01/10/2012 A Shipping Address is required.
*Shipping ATTENTION:
Shipping Company:
*Shipping Phone Number:
*Shipping Street Address 1:
Shipping Street Address 2:
*Shipping City:
*Shipping State/Other:
*Shipping Postal Code:
Shipping Country:
Shipment Priority
*Date Monitor Should Arrive At Site:Please select a valid date(mm/dd/yyyy).
The monitor will be shipped to arrive on this day.
*Shipping Method:
FedEx is the prefered Carrier
Typical package:
Weight: 20+lbs
Size: 17' x 20' x 8'
Shipments come from:
Rx Monitoring Services, Inc.
22a Eastman Ave
Bedford, NH 03110 US
603.666.6606
Account Number:
Equipment Information
*Name/Model Of Equipment To Be Monitored:
*Plug/Receptacle Type Needed By Equipment:
HELP

If unsure, please describe plug in the 'Notes' section below
Equipment Age:Round to nearest month or year
Equipment Voltage:
Power Conditioner:
Notes
Generally, Rx staff will be able to determine the configuration of equipment needed for the survey. However, if you have any special requirements, such as plugtype, line-impedance(Z-Brick), only monitor temperature&humidity or are having problems at the site, please make note of them here:
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