Return Form for
Power Supply Repair		 Ship power supply (and form) prepaid to:
 MODUMEND
5506 Adolfo Road
Camarillo, CA 93012

 Repair estimate was obtained from ACME Process Equipment Company at (317) 846-3321.

Estimated repair cost:

Power supply information:

Make:
Model:
S/N:
Tag # :

Description of failure symptoms:
Be sure to mention any extreme service conditions or other useful information.

 Contact me if the repair charge varies by more than 10% from the estimate.
 Send "as-found" report on replaced components.

Turn-around time required:
 5-10 days bench repair time is satisfactory.
 48-hour expedited repair (additional charge).

If available, please include a copy of any schematics or configuration documents.

Contact for technical questions:

Name:
Phone:
Fax:
E-mail:
GO BACK 		 
Date of shipment:

Customer company (name, mailing address)

Contact for payment or business questions:

Name:
Phone:
Fax:
E-mail:

Return shipping information:
Please type your return shipping label below:

Include purchase order #, job work order #, or any special package markings.

 Ship by UPS Surface.  If not UPS Surface, indicate alternate shipping instructions:
 

Form of payment:

 MasterCard 
 VISA  
AMEX
 C.O.D.
Card Number:
Expiration Date: