Name
E-mail Address
Phone Number
Street Address
City, State, Zip Code
Camera Camcorder Projector VCR Monitor TV DVD Plasma TV PS2 or Xbox Audio Other   Category

Brand Name

Model
Serial
Place of Purchase (If under warranty)
Purchase Date
City where Purchased

Malfunction of Unit and additional Comments:

Express Repair Center, Inc. requires an advanced payment of (Please call for amount. Amount varies on unit) for all units not covered by a service contract or factory warranty. This advanced payment will be applied to the repair of the unit. If the estimated  given is declined, this fee becomes our diagnostic charge and is not refundable. delivery charges will be additional for ship in service, and are calculated by zip code.

We accept Master Card, Visa, American Express, Discover and Personal Checks:

Credit Card Number
Credit Card Expiration Date
Name as it appears on Card

CVV2 Number
I accept pay the advanced payment of (Please call for amount. Amount varies on unit) and understand this payment will be applied to the repair.

If the estimate given is declined, this payment becomes the diagnostic fee and is not refundable.