SERVICE REQUEST FORM
CUSTOMER INFORMATION
Name _____________________________________________________
Company __________________________________________________
Address ____________________________________________________
City _______________________________________________________
State _________________________ Zip Code_____________________
Phone ________________________ Fax _________________________
Purchase Order Number _______________________________________
Service Required _____________________________________________
Please provide the following information:
Manufacturer/Model _____________________Serial ________________
ESTIMATE: Prior to repair, we will fax a written estimate of all costs to repair instrument(s).
A $75.00 (per instrument) service fee applies to all rejected estimates.
NEW ACCOUNTS: We require 1 bank and 3 trade references to set-up new account.
WE ACCECPT VISA, MASTERCARD, & AMERICAN EXPRESS.
Note: This completed form should be included in box with instrument(s).
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