United Camera Repair Form

UNITED CAMERA REPAIR, INC.
Repair Form

Please print this entire form and send it with your product to the address below.

(Information entered into this form online will not be collected or stored by United Camera Repair, Inc. at this time.
Please send this form to the address below for processing.)

First name:

Last name:

Phone:

Cell Phone:

E-mail address:

Address 1:

Address 2:

City:

State:

ZIP:

Make:

Item Type:

Model:

Serial #:

Problem:

Diagnostic Fee: Camcorders-$36.50, IPods-$18.50, Video Games-$36.50, Photographic Equipment-$18.50

Check

A Check for the Diagnostic Fee is enclosed.

Credit Card

Please bill my Credit Card for the cost of the Diagnostic Fee.

Pre-Approved

Please repair my camera if the cost is at or below
Notify me if the cost exceeds this amount.

Name on credit card:

Credit card type:

Credit card number:

Expiration Date:

3 Digit Validation Code:

Send Product To:

United Camera Repair, Inc.
3830 14th Avenue
Rock Island, IL 61201

Please ship your product via a carrier service with a means of tracking your package. Insure all shipments and please keep a record of the tracking number and product serial number in the event you must trace the package.
United Camera Repair, Inc. will not assume responsibility for loss and/or damage during transit.
If you have any questions please contact United Camera Repair, Inc. at 1-(877)-786-0958