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Date:  04/19/2024  PO Number:

Customer Information

Customer Name*


City*  State*  ZIP*

Phone Number*


Equipment Information

Equipment Manufacturer: 

Model Number: 

Serial Number: 

To insure proper service, please indicate the problem with the equipment*:

NOTE:  A minimum $85.00 diagnostic fee will be charged on all equipment brought in for repair.  All equipment that has been repaired must be picked up within 60 days of the repair.  Equipment not picked up within 60 days of the repair becomes property of Active Imaging Services, LLC.
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