Master Appliance Repair Service

To ensure correct contact information, please fill out this page, and click submit. On the following page your information will be displayed for printing. Please send it with your tool for repair.

	* indicates required fields
First Name*
Last Name*
Company Name
Address*
Address (cont.)
City*
State/Province*
Postal Code*
Country*
Phone*
Fax
Email*
	Would you like to be added to our mailing list for new product updates?
	Yes, send info via email Yes, send info via US Mail No, leave me alone

Packing Slip Included:	Yes No
Receipt w/ Purchase Date:	Yes No
Date Purchased
Customer Tag #
Customer Reference

	Payment Method:
Payment Enclosed:	Yes No
Check #
Credit Card Type:	Visa MasterCard
Name On Card
Credit Card #	(you will not be charged now, charges will be applied when we receive and complete your repair order)
Expiration Date
Credit Card Security Code#	(the last 3 digits on the back of your credit card)

	Product Returned:*
	Quantity Model Number
	Quantity Model Number
	Quantity Model Number

	Reason for Repair:*
	(Please include a brief explanation of the problem):