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___________________________