DMI Marine Repair Request Form

52 Center Street, Middleborough MA 02346 tel: 774-213-9744

Name: ___________________________________________  Date: _______-_________

Company (if needed for return address) _________________________________

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 (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)?
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)

*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 _____________