18 Commerce Park Road, Pocasset MA 02559 508-564-7491
Name: ___________________________________________ Date: ________________
Company: ________________________________________
| Shipping Address: | _________________________________________________ _________________________________________________ _________________________________________________ |
Please check () the best way to reach you.
Phone Number with Area Code: ________________________________
Cellular Number: _______________________________
Email Address: ______________________________________
Total number of instruments shipped with this repair: 1 2 3 Other: ______
Credit Card Number: __________/___________/___________/___________ Exp. Date: _____/______
Repairs under $150 per instrument will automatically be completed (masthead counts as one instrument)
Do you authorize automatic repairs over $150 (for each instrument)?
No, contact me first
Yes, up to $___________per item (this will result in a
quicker repair since we can avoid extra phone calls)
| Instrument Name | Model | Serial Number | Problem Details (continue on reverse if needed) | |
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| 2 | |
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| 3 | |
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*For repairs less than $150 per instrument, we will automatically charge the repair fee to this credit card, and return the repaired instrument(s) to you via UPS Ground service (Continental US only), unless you indicate another shipping preference. For repairs over $150 per instrument, we will contact you for approval before the repair is completed. If you decline the repair, a bench charge of $75 will be assessed for each instrument sent in. Please include a telephone number and/or email address.