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PART I – CUSTOMER DATAPART II – MAINTENANCE ACTIVITY DATA1a. UIC FORMTEXT ?????1b. UNIT NAME FORMTEXT ?????1c. PHONE NO FORMTEXT ?????4a. UICW05J084b. DODAACW81PYK4c. ACTIVITY NAMEMedical Maintenance Operations Division - UT2a. DODAAC FORMTEXT ?????2b. POC FORMTEXT ?????2c. DSN FORMTEXT ?????5a. POCAdministrator5b. PHONE 801-586-50935c. DSN586-50933a. EMAIL FORMTEXT ?????6a. 2nd POCProduction6b. PHONE801-586-49496c. EMAILMCMR.USAMMA.MMOD-UT@us.af.milEQUIPMENT RETURN TO ADDRESS - CUSTOMEREQUIPMENT SHIP TO ADDRESS – MAINTENANCE ACTIVITY FORMTEXT ?????DODAAC: FORMTEXT ????? FORMCHECKBOX DODAAC Same as aboveATTN: Production ControlUS ARMY MEDICAL MATERIEL AGENCYMEDICAL MAINTENANCE – UT6149 WARDLEIGH ROADBLDG. 1160, BAY 1HILL AFB, UT 84056-5848PART III – CUSTOMER OPTIONS FORMCHECKBOX Request email status update FORMCHECKBOX Request EXCHANGE OPTION (IF AVAILABLE)Requires Property Book transactions. Serial number will change. FORMCHECKBOX Check if Unit is deploying OCONUS.Provide date of Deployment and Commander Memorandum.PART IV – EQUIPMENT LISTNOTE: Per CDC, contaminated equipment must be disinfected with a 1:10–1:100 dilution of 5.25%–6.15% sodium hypochlorite (bleach: water).GCSS Work Order #NSNNOMENCLATURESERIAL NUMBERSYMPTOM/FAULT FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????ADDITIONAL INSTRUCTIONS: **PLEASE REMEMBER TO INCLUDE THE GCSS-ARMY WORK ORDER FOR ALL DEVICES**Please provide the following for each equipment item (whenever possible):1. All accessories (power cord, ECG cables, etc.).2. Manufacturer service literature for non-standard equipment (if available).If the equipment is not repairable it will be condition coded IAW AR 725-50. The owning or supporting unit will be notified to determine the disposition of the device(s). SHIPPING INSTRUCTIONS:1. Properly pack the equipment to ensure it is not damaged in shipping.2. Attach this form to each shipping container.For questions, please call: 801-586-5093, DSN: 586-5093GCSS Work Order #NSNNOMENCLATURESERIAL NUMBERSYMPTOM/FAULT FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????ADDITIONAL INSTRUCTIONS: **PLEASE REMEMBER TO INCLUDE THE GCSS-ARMY WORK ORDER FOR ALL DEVICES**Please provide the following for each equipment item (whenever possible):1. All accessories (power cord, ECG cables, etc.).2. Manufacturer service literature for non-standard equipment (if available).If the equipment is not repairable it will be condition coded IAW AR 725-50. The owning or supporting unit will be notified to determine the disposition of the device(s). SHIPPING INSTRUCTIONS:1. Properly pack the equipment to ensure it is not damaged in shipping.2. Attach this form to each shipping container.For questions, please call: 801-586-5093, DSN: 586-5093This form may be reproduced but shall contain the same information as it appears on this form. ................
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