Hardware Request

Hardware Request Form

Please use this form to request actions related to hardware, including shipping or delivery, returning, replacing, or updating the inventory status of Valis hardware (including ACAM kits, ValisR eCOA kits, eDiary Devices, Trial.Training tablets, and other Valis hardware).

Name *

First

Last

Email *

Sponsor *

Please enter the name of the study or research sponsor/company.

Study or Program (if applicable)

Please enter the study the request is related to, e.g. STUDY-101

Description of Request: *

Hardware *

Select the hardware the request pertains to

Does this request require shipping? *

Shipping Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Please enter the full shipping address if applicable.

Comment