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Repair Type

Existing Customer:		Repair Type:
Under Warranty/Contract:		Account/Contract/Warranty Number :		Do you require a Repair/Service Order number prior to sending in equipment? :

Shipping Information*

First Name:	Last Name:
Street Address:	Site Name,Location:
City:	State:	Zip/Postal Code:
Phone Number:	E-mail Address:

Equipment Information

Billing Information*

First Name:	Last Name:
Company:
Street Address:	Suite / Apt:
City:	State:	Zip/Postal Code:
Phone Number:	E-mail Address:

Additional Shipping & Billing Information

PO Number (Required id all Flat Rate Repairs) :		Return Shipping Method :
Shipping Account Info (if being billed on customer supplied shipping account) :
Additional Comments :

Additional Comments

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Send to:
Data Capture Solutions
160 West Road
Ellington, CT 06029.

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