Product Repair Authorization Form

Please indicate if you are a Dealer or an End User

Dealer # (if applicable)
Dealer Name (if applicable)
End User

Repair applicable) Needed

Enter Dealer or End User Name

For Dealer Include Company/Organization Name (if applicable), or for End User Enter Full Name above.

Billing Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Shipping / Return Address (if applicable)

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone Number (include international dialing code if applicable)

Email Address

Email

Confirm Email

The Best Way to Contact You

Phone
Email

Product Name / Model Number

Owner Name

Serial Number

Date of Purchase

This item is covered by warranty. File Upload

Drag & Drop Files, Choose Files to Upload You can upload up to 2 files.

Important: Kindly provide a copy of your original purchase receipt, as warranty service cannot be assured without it.

For Covered by Warranty - Please share the details about the issue you’re experiencing with the product, including the circumstances in which it malfunctions.

This product IS NOT under warranty. Describe the Problem / Repair Needed

Please repair and return immediately and call only if repair cost is 50% of the retail value of the product or exceeds $100.00.

Preferred Repair Option

Please choose your preferred option from the drop-down menu.

Authorization

I authorize the product repair and understand charges may apply.
I agree to the repair terms and any applicable warranty limitations.
I confirm the product is backed up (if applicable) and data loss is not the repair center’s responsibility.
I authorize return shipping to the address provided (if applicable).

Customer Signature (Repair Authorization)

Clear Signature

Today's Date

Phone

Custom Captcha

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Product Repair Form for AgraTronix™ Products

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