Equipment Repair Form

1. Customer Information
Customer Name
Contact Name
Phone Number
- -
Shipping Address
Fax Number
- -
City
Suite No.
Province
Postal Code
-
Department (if applicable)
2. Equipment Information
Model

Serial Number

Accessories Included
Battery Antenna Belt Clip Charger

Other

3. Reason for Repair
Please check all that apply
No Transmit/Receive
Keypad
Static
Missing Buttons
Display
Distorted Sound
Antenna Connector
Battery Contact
Intermittent (describe)
        

Other
        
4. Form of Payment
Please check all that apply
Estimate Required
Yes       No

(if "No" please provide
Purchase Order Number)

P.O.#
A repair estimate will be provided automatically if repair exceed $150.

Maintenance Contract
Account
Cash
Credit Card
       American Express
       MasterCard
       Visa
Credit Card Number

Exp. Date



__________________________
Signature
Customer shall pay for all repairs not covered by warranty.
5. Pick Up
Call when repair is ready       Ship when radio is ready (a $20 shipping & handling fee charge will apply)
NOTES

_________________________________________________ Date (DD/MM/YYY)
Signature

Bring COMPLETED Form
along with equipment