Order Repair Form (Fields marked with * are required) | |||
Customer Info | |||
Address Line 1: | |||
*Customer Name: | A value is required. | Address Line 2: | |
*Contact Name: | A value is required. | City: | |
Business Phone: | Province/State: | ||
Home Phone: | Country: | ||
Mobile Phone: | Postal/Zip Code: | ||
Fax: | *E-mail: | ||
Repair Info | |||
*Make: | Please select an item. | Ticket #: | |
*Model: | Tracking #: | ||
Serial No: | Ship Via: | ||
Condition: | Drop off location: | ||
Person Received By: | Pick up location: | ||
Under Warranty? | Yes No Select Only One | ||
Problem: | |||
Private Notes: | |||
Warranty Information | |||
Purchased From: | Purchase Date: | ||
Please remember to include copy of sales receipt. | |||