Please fill in the form and e-mail it to aftersales-fr@samsongroup.com

Product identification (to be filled in by the customer)

NCR issued by (name): Enter text E-Mail: Enter text	Date: Select Date	Your internal NCR no.: If applicable Enter text
Customer’s company: Enter text	Enduser: Enter text
Original SAMSON REGULATION SAS order no.: Enter text	Project name: Enter text If applicable

Product information

VAR ID: Enter text	Quantity: Enter text
Tag no.: Enter text If applicable	Serial no.: Enter text If applicable
Where is the equipment: Enter text	Return to SAMSON REGULATION SAS: ☐ Yes ☐ No

Description of non-conformance

Enter text

Non-conformance was found during:

☐	Incoming inspection	☐	Loop check
☐	Installation	☐	Other: Enter text

Urgency

☐	High	☐	Medium	☐	Low

To be filled in by SAMSON REGULATION SAS:

In-house NCR No.: Enter text	Date of receipt: Select Date
Processed by: Enter text	Received by: Enter text