Evaluation Reservation Form


Company Name: *
First Name: *
Last Name: *
Job Title: *
Street Address 1: *
Street Address 2:
City: *
State: *
Zip Code: *
Phone: *

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Phone Ext:
E-mail: *
Product Being Evaluated: *

I hereby accept full responsibility for the following Evaluation equipment on loan from MIDCOM Data Technologies (MIDCOM). I will return this equipment via traceable means, to the mailing address (33493 W. 14 Mile Rd, Suite 150, Farmington Hills, MI 48331) within ten (10) days after I receive the equipment. I understand that if the equipment is not shipped back to MIDCOM within ten (10) days from the time of receipt, my company agrees to be invoiced for the List Price of the equipment and agrees to pay that amount within fifteen (15) days of invoice date. Additionally, I agree to the additional terms and conditions listed below which also govern the use and return of this equipment.


Agreed to:

1. MIDCOM will not be liable for any consequential damages, loss or expenses arising in connection with the use or the inability to use its product or goods, for any purpose whatsoever.
2. The above company agrees to provide free access to MIDCOM employees to inspect, service, and remove the equipment at the sole discretion of MIDCOM.
3. The above company assumes risk of loss or damage for the above named product and takes the responsibility for adequate shipping insurance when returning said product.
4. Should customer wish to return the product, the above company will call MIDCOM’s office and receive directions on where and how to return the equipment.
5. The above company agrees to ship back the equipment prepaid in the original factory box with all packing material and to seal the carton with clear tape only. If returned product is not in the original packing material, customer agrees to pay for new box and packing material.
6. Included in each box in addition to the requested equipment: ( ) Guide ( ) Power Cord ( ) Warranty Material ( ) Packing Material.
7. If product does not meet customer’s performance needs within ten days, upon return to MIDCOM, we will credit your invoice.


Digital Agreement Signature: *

800-643-2664