ASSOCIATES COUNTRYMAN INC.
195 Constitution Dr. Menlo Park, CA 94025 Phone [phone]
REPAIR INFORMATION FORM
Customer Information
Company Name: _________________________________________ Contact Person: __________________________________________ Billing Address: ___________________________________________ City: ____________________________ State: ____ Zip: __________ Shipping Address : _________________________________________ City: ____________________________ State: ____ Zip: __________ Date: ___________________________ Fax: ____________________________ Email: ___________________________ Phone: __________________________ Countryman Associates does not ship to P.O. Boxes
Shipping Recommendations
You, the customer, are responsible for your product's safe arrival at Countryman Associates. We recommend you ship your product to us by a method that gives you a signed delivery receipt, tracking number and insurance for the replacement value of your product. Good methods include Federal Express, UPS or Express Mail.
Product Information
Quantity: Model ___ Number: ______________ Serial Number: ______________ Purchase Date:____________ Description of the problem: _______________________________________________________________________ ______________________________________________________________________________________________ Quantity: ___ Model Number: ______________ Serial Number: ______________ Purchase Date:____________
Description of the problem: _______________________________________________________________________ ______________________________________________________________________________________________ If you are returning products for warranty service, please include a copy of your purchase receipt, if available.
Payment Information
Account # ______________________________________ Circle One: VISA MC AMEX CAI open account
Name on account: ___________________________________ Security Code: _________ Exp. Date: ____________ I authorize repairs up to $ __________ Plus Tax without being called first. Signed: __________________________