TONER REQUEST FORM FOR FULL SERVICE MAINTENANCE AGREEMENT MACHINE

Company name: ADB BVBA Requested by:

Machine Model: Canon C5255i Telephone No:

Serial No.: Date: (dd/mm/yy) 19/05/19

Please fill your toner requirements in the below table and send the form to helpdesk@canon-emirates.ae or Fax (Dubai)
04-3306656 or Fax (Abu Dhabi) 02-6262687.

Toner Model Current stock Required Quantity Location

Cyan 01 1 A
0

Please note that the requested quantity is subject to validation by canon emirates based on the actual print volumes since last delivery.
The approved quantity may vary from the requested quantity in the above table. This form is valid for one machine only, should you
need to order toners for another machine, please fill another form. The expected date of delivery is next business day had the request
been received before 2:30pm.

Kindly press the small button ‘123’ on the machine’s panel and enter the counters readings in the below fields.
The below fields 112, 113, 122, 123 are mandatory and we cannot process the order without them. For Black and white
machines, counters 122 & 123 are not applicable.

112: 1932 113: 39714 122: 42483 123: 339186

Below table is For Canon Emirates use only – PLEASE DO NOT FILL

Toner Model Last Delivery Date Delivered Quantity Achieved yield % Approved QTY Previous reads

112:

113:

122:

123:

Validated by: Date:

Canon Emirates LLC

Dubai, P.O Box 1700, Tel +971 4 350 2500, Fax +971 4 330 6656 | Abu Dhabi, P.O Box 108594, Tel +971 2 697 5000, Fax +971 2 626 2687
Help Desk: 800 – Canon (800-22666) | email: helpdesk@canon-emirates.ae | www.canon-emirates.ae