Shipping Form Form Page 1 of 3Company NameIf item is being checked in for a company or an organization, please provide the name here.First Name *Last Name *Email *Daytime Phone *Alternate PhoneShipping Address *City *State *AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonMarylandMassachusettsMichiganMinnesotaMississippiMissouriPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip * Back Next Page Form Page 2 of 3Equipment Manufacturer *Brand of EquipmentModel Number *Serial Number *Description of Problem * Back Next Page Form Page 3 of 3Billing Type *WarrantyNon-WarrantyPlease upload a .PDF copy of your original purchase receipt: *Service Type *4-6 week turnaround, lead time varies, no additional charge$25.00 diagnosis in one business week$50.00 diagnosis in one business dayPriority service is an expedited diagnostic service performed within the specified period it is not a statement date of repair completion.* I have read the terms and conditionsTerms and Conditions of Account between Customer and Audio Electronics DallasnThe customer engages Audio Electronics Dallas for technical services and hereby agrees to the company’s terms and conditions as set forth. In addition, the customer agrees to the product category Service Minimum Schedule fee and if elected Priority Service fee. Should services require exceeding the product category scheduled minimum amount; the customer is provided an estimate for approval before proceeding. Service minimum amounts collected during equipment check in, apply towards final service invoice total.nPlease note estimates do not include applicable sales tax or applicable freight charges.nnPayment Due at Check-InnVaries from $20 - $160. The amount due is determined based on the customer’s equipment category as defined in the Service Minimum Schedule + any elected Priority Service + applicable Sales Tax. Payments received at check-in apply towards approved or declined estimates.nWarranty Service Statement:nAudio Electronics Dallas is an Independent Authorized Service Center for numerous equipment manufacturers and accepts most warranty service requests. Audio Electronics Dallas assumes its customers requesting product service under manufacturer’s coverage have read and understand the terms and coverage limitations of their product warranty. Equipment accepted under a warranty request could later be determined as not eligible due to the manufacturer warranty policy or coverage limitation and may incur a service charge. The determination of warranty eligibility can only be made once our technicians have diagnosed the product and administration has determined if the product falls within the manufacturer’s guideline for warranty coverage. It is at this juncture of the process that we are able to determine product eligibility. Should a product be determined as not eligible for warranty coverage, an estimate is provided to the customer for their approval.nIn cases of product not be eligible for warranty coverage, the customer agrees to the Service Minimum Schedule CHARGE for their product category or the approved estimate CHARGE, which ever is applicable.nTERMS & CONDITIONSnIn addition to the above, customer also agrees to the following additional items when applicable:nCharges, fees, and expenses which are not eligible under manufacturers warranty or other extended warranty plans. Collection and legal fees incurred by Audio Electronics Dallas should the customers account become delinquent and or unpaid.nCustomer notification is made upon service completion via telephone, email, or post card.nEquipment unclaimed 15 days past service completion is subject to storage fees of $4.00 per day. Equipment unclaimed past 30 days from completion is considered abandoned and become the property of Audio Electronics and will be disposed accordingly.nShop warranty on non-warranty repairs is 30 days for repairs covering original parts and labor.nCustomer is responsible for all transportation costs associated with the delivery or return of their equipment.nOn equipment shipped back to customers, customer agrees to NOT hold Audio Electronics Dallas liable for any shipping damage that may occur due to mishandling of their equipment by the freight company.nDISCLAIMER – The customers agrees that Audio Electronics Dallas shall not be held liable in any event for indirect, incidental, or consequential damages associated with services provided. I authorize Audio Electronics Dallas to evaluate and operate my equipment at my sole risk for purposes of diagnosis, testing and repair. I accept responsibility for backing up any stored data on said equipment and I will not hold Audio Electronics Dallas liable for any lost data that might occur.nYour digital signature: *Clear