The United Republic of Tanzania
Ministry of Industry and Trade
Weights and Measures Agency
Misugusugu Wakala Wa Vipimo
Mob: 0784 729 365 · Tel: 0784 729 365 · P.O Box 30386, Kibaha · misugusugu@wma.go.tz
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Weighing Instrument Repair Referral
Weights & Measures Act - Referral for Repair of a Failed Instrument
Referral & Application Reference
Referral No.:
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Application No.:
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Customer Information
Customer Name:
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Phone:
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Instrument Details
| Instrument Type | {{ $instrumentType ?? '' }} | Serial Number | {{ $serialNumber ?? '' }} |
| Manufacturer / Model | {{ $manufacturerModel ?? '' }} | Verification Site | {{ $verificationSite ?? '' }} |
| Collection Center | {{ $collectionCenter ?? '' }} | ||
Reason for Repair Referral
Determination
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Repairer / Form D Reference
| Referred Date | {{ $referredDate ?? '' }} | Repairer Reference | {{ $repairerRef ?? '' }} |
| Repairer Name | {{ $repairerName ?? '' }} | Region / District | {{ $repairerRegion ?? '' }} / {{ $repairerDistrict ?? '' }} |
| Form D Reference | {{ $formDRef ?? '' }} | Form D Status | {{ $formDStatus ?? '' }} |
Verifying Inspector
Signature & Stamp
Repairer Acknowledgement
Signature on Receipt of Instrument
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