Equipment Repair Request Form

Please complete this form and send it along with the item being repaired.
If you are sending an item for repair, receipt of this completed form will expedite the repair process.
You will receive a RA# within 1 business day of submitting this form
FIELDS MARKED WITH * ARE REQUIRED!
Mr./Mrs./Ms. Brand
Name* Model #
Company Serial #
Address* RA #:
 ____________(Please Print)
Apt/Suite
City*
State*
Zip Code* -
Country*
Phone* ()-
Email*
Description of Problem
(Be Detailed)
You will receive a RA# within 1 business day of submitting this form. Write in the RA # you receive in the space provied on the form. Please Include a copy of this form with your equipment. If you do not send this form with your equipment it will delay repair and processing time.
Estimate Requested:  
By: E-MAIL: 		After receiving your estimate, If you decide you don't want your equipment repaired there is only a $25.00 fee for estimate preformed plus return shipping & Insurance. If you decide to have your equipment repaired this fee will be wavied.

AUTHORIZED SIGNATURE TO DO REPAIR OR ESTIMATE: 

Sign Here:_______________________(Required)   Date:_____________




If Paying by Credit Card Please Fill out & Sign This Form and Send With your Repair
Credit Card Infomation
We Accept
Money order / cashiers check
(NO PERSONAL CHECKS OR BUSINESS CHECKS)


Card #:______________________________________ Exp.____/_____

Card ID:____________ (Required) The Card ID code is the 3 digit code found on the back of your card. Click here for a diagram to locate this on your Visa or MC


Name on Card:___________________________________


Billing Address:__________________________________

City:______________________ State:__________ Zip:_________


Cardholder Signature:______________________ Date:__________
By signing the you agree to have radioshopsupplies.com charge your credit card for the total amount plus shipping on the repair of your equipment.
Please Print this page using the Print Button below before Click the Submit button