1. CYTOSUR GE AG, SÄGEREISTRASSE 25, CH - 8152 GLATTBRUGG, SWITZERLAN D PHONE +41 43 544 87 0 0 , FAX +41 43 544 87 0 9 , [email protected] , WWW.CYTOSURGE.COM 1 /2 FluidFM ® PROBES WARRANTY REQUEST FORM We are sorry to hear that you are having problems with our probes. Together with our distributors we are going to do our best to help you as soon as possible. This form is used to initiate the warranty request procedure for probes which do not meet the spe cifications. To process and assess your warranty request quickly, we ask you to send an e- mail with this filled form attached to our specific distributor – or to [email protected] if you are a direct customer of Cytosurge . Please do not send any probes back without explicit request and instructions from us, as this will result in customs and VAT charges. INSTRUCTIONS The table below is for one or more probes of the same type with the same issue. If you want to complete the form for a further probe type / issue, please copy the whole table. 1. Probe/ group of probes a. Choose unmet specifications or issue Serial nu mber(s) (CYSN) : Probe t ype: FluidFM platform: Other: Application in: a) liquid b) air Probe(s) were used for following application: Other:

2. CYTO SURGE AG, SÄGEREISTRASSE 25, CH - 8152 GLATTBRUGG, SWITZERLAN D PHONE +41 43 544 87 0 0 , FAX +41 43 544 87 0 9 , [email protected] , WWW.CYTOSURGE.COM 2 /2 Unmet specification (s) /i ssue(s) : a) the p robe(s) v isibly le ak(s) b) the probe(s) c annot b e filled c) the p robe a dapter(s) d o/does n ot fit tightly o r is/are broken d) no o r bad l aser signal e) oth er , please specify : b. Proof that you will send us a s attac hment Which proof are you sending us for each probe or group of probes? a) video b) im age c) sketch d) other c. Please enter a detailed description of the problem (also tell us your assumption of possible causes) Detailed problem description: Assumption(s) of possible causes: d. Used experimental protocol Did you use a standard protocol from Cytosurge? Yes, p lease specify: No, p lease sp ecify y our ow n p rotocol: T h a nk y ou for t aking t he ti me t o he lp us imp rove ou r pr oducts a nd serv i ces!