Minilec Service Inc. - iPod Repair Form

Customer Information

Account # (if known) __________________

Name _____________________________

Address (no PO boxes)_________________

__________________________________

City ______________________________

State __________ Zip _______________

Day Phone #____________________________

Fax # _____________________________

Service Requested:		Charge:			Shipping	Charge:
o	Diagnostics	19.95
o	Replace Gen 4 Battery	29.95		o	UPS Ground service	9.95
o	Replace Pho/Col/Vid Batt.	39.95
o	Replace Motherboard	99.95		o	2nd-Day Delivery	19.95
o	Replace 30 GB HD Video	169.95
o	Replace 60 GB HD Video	249.95		o	Next-Day Delivery	24.95
o	Replace Gen 4 LCD	99.95
o	Replace Photo LCD	99.95		o	Destination is HI or AK	29.95
o	Replace Video LCD	99.95
					Shipping Charge Amount	________
	Subtotal:	________
	Tax:	________	Add 8.25% in California
	Shipping Charges:	________	(Please select one of the above delivery methods)
	Total:	________	Your iPod is: o Win, or o Mac formatted.

Billing Information
iPod will be returned unrepaired if you do not send payment
Payment Enclosed:				Sorry, we do not accept AmEx
	o Cashiers Check	o Money Order	o Company Check	o Credit Card (Visa or M/C only)

Credit Card # __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Exp.Date:____/____Mo/Yr

(Credit card numbers are Confidential Proprietary Information)

Print Name of Card Holder ___________________________________________________

Signature of Card Holder ____________________________________	Date ___________

Minilec warrantees it's repair labor and replacement parts for 30 days.

Rev. 09/04/06

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