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Please print this entire form and send it with your product to the address below.
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(Information entered into this form will not be collected or stored by United Camera Repair, Inc. at this time.
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Please send this form to the address below for processing.)
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First Name:
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Last Name:
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Phone:
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--
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Cell Phone:
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--
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E-Mail:
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Company Name:
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Address 1:
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Address 2:
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City:
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State:
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Zip Code:
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-
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Type:
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Diagnostic Fee: $
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Make:
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Model:
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Serial #:
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Problem:
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Check
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A Check for the Diagnostic Fee is enclosed
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Credit Card
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Please bill my Credit Card for the Diagnostic Fee
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Pre-Approve
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Please Repair if the cost is at or below: $ Notify me if costs exceed this amount
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Please call for Credit Card Information.
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Name on Card:
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Card Type:
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Number on Card:
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Expiration Date:
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/
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3 Digit Validation Code (on back of card)
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Send Product to:
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United Camera Repair, Inc.
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3830 14th Avenue
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Rock Island, IL 61201
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Please ship your product via a carrier service with a means of tracking your package. Insure all shipments and please
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keep a record of the tracking number and product serial number in the event you must trace the package.
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United Camera Repair, Inc. will not assume responsibility for loss and/or damage during transit.
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If you have any questions please contact United Camera Repair, Inc. at 1-(309)-786-0950
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