TACKLE SERVICE CENTER

REPAIR REQUEST

(PLEASE PRINT)

                  #1      DATE            /        /            

                  #2      NAME :___________________________________________________________

                           SHIP TO ADDRESS:_________________________________________________

                           CITY, STATE, ZIPCODE:_____________________________________________

                           E-MAIL ADDRESS: _________________________@_______________ . ______

                           DAY PHONE NUMBER:                 1- ( __ __ __ ) - ( __ __ __ - __ __ __ __ )

                  #3      ITEM FOR REPAIR:     ________ WARRANTY    ________ NON-WARRANTY

                            WARRANTY REPAIRS MUST BE ACCOMPANIED BY A COPY OF THE PROOF OF PURCHASE-NO EXCEPTIONS

                           ITEM:____________________________BRAND:__________________________

                           MODEL #:________________________SERIAL #:_________________________

                           PROBLEM:_________________________________________________________

                           ___________________________________________________________________

                           ___________________________________________________________________

                           SPECIAL INSTRUCTIONS:___________________________________________________

                           ___________________________________________________________________

                  #4      PAYMENT INFORMATION------AUTHORIZATION------CHARGE MY CARD

                                       _______ VISA _______ MASTER CARD _______ DISCOVER

                           NAME ON CARD:____________________________________________________

                           ACCT NUMBER :_____________________________________________________

                           ACCT EXPIRATION DATE:______________3 DIGIT CODE ON BACK________

             Signature___________________________                                                                                                            USE A SEPARATE SHEET FOR EACH ITEM TO BE SERVICED