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