Electronic Instrument Repair Form

Line Items: 0
Total Items: 0
Sub Total: $0.00

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Applicable Tax and Freight Charge will be added to Final Invoice.

Electronic Instrument Repair Form

We can Pick it up, Repair it, and Return it to you with a Call Tag Request!

Please fill in the following form then click the SUBMIT button to forward your request, and be sure to include an e-mail address or fax number for our follow up.

Check the UPS Call Tag Button if you would like us to issue one to have your instrument(s) picked up. Give us the information below and we will do the rest! NOTE: All Freight Charges will be simply added to your final invoice.

Click here for printable PDF form.

* denotes a required field

	Issue a UPS Call Tag to have my Instrument(s) Picked Up.
	This is an Emergency Repair!
	I need an Estimate before any repairs are made.
	I think this should be covered by my Warranty.
Instrument Purchased		Original Invoice


	How do want your Instrument(s) Returned?

INVOICE TO
First Name*		Last Name*

Company Name
Address*

City*			State*
Country*			Zip Code*
Telephone*			Ext
Fax
Best Time to Call			Time Zone

eMail Address*
Anti-Spam, please enter 1234 *

SHIP TO
First Name*			Last Name*

Company Name
Address*

City*			State*
Country*			Zip Code*
Telephone*			Ext
Fax

OTHER INFO
PO Number
Type of Instrument
Serial Number

Describe the Instrument's Problem(s)



SHIP YOUR INSTRUMENT TO:
		POLLARDWATER.COM REPAIR CENTER 200 Atlantic Avenue New Hyde Park, New York 11040