52 Center Street, Middleborough MA 02346 tel: 774-213-9744
Name: ___________________________________________ Date: _______-_________
Company (if needed for return 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 (masthead counts as one instrument): 1 2 3 ______
Repairs under $150 per instrument will automatically be completed
Do you authorize automatic repairs OVER $150 (for each instrument)?
|Instrument Name||Model||Serial Number||Problem Details (continue on reverse if needed)|
*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) or by mail at our discression. 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.
MC \ VISA\ Discover Credit Card Number: __________-___________-___________-___________
Exp. Date: _____-______ Verification 3 digit code: ________ CC billable zip code _____________