Minilec Service, Inc.
  9207 Deering Avenue, Suite A
Chatsworth, CA 91311
 
                          

How Did You Find Minilec Service? (Circle One)

Carrier
recommendation		 Carrier sent to
manufacturer		 Called
manufacturer direct		 Yahoo
Recommended
by a friend		 Flyer On line
search		 Google
Customer Information
Account # (if known) __________________
Name ____________________________
Address (no PO boxes)_________________
__________________________________
City ______________________________
State __________ Zip _______________
Day Phone #__________________________
Fax # ____________________________
Email: ____________________________
 
Date ______________________________
 
Phone Information
Model_____________________________
Serial Number ______________________
Carrier / Service Provider _____________
Mobile Number _____________________
Customer Complaint _________________
___________________________________
___________________________________
 
Service Requested:      
 o Repair Only  

Warranty Labor:  

No Charge
 o Repair & Replace Case Parts

Out of Warranty Labor:  

$23.95
 o Unlock (Key & Security)

Warranty Parts:  

No Charge
 o Upgrade Software

Out of Warranty Parts:  

M.S.R.P.
       
Not to exceed parts cost of:      
 o $25 o $50 o $75 o $100 o Call w/ Estimate
 
If there is any Physical Damage to the Phone, it will NOT be covered under warranty. 
Price for an out of warranty repair is $23.95 for Labor - Plus the parts cost. 
Minimum $19.95 inspection fee. 
 
I understand that during the repair process I may
lose my address book and other stored information.		 o Do not repair

 Customer
Initial:

     
o OK to Erase
 
Billing Information
Cellphone will be returned unrepaired if you do not send payment
Payment Enclosed:
    o Credit Card - Visa   o Credit Card - MasterCard
Credit Card # __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ Exp.Date:____/____Mo/Yr
(Credit card numbers are Confidential Proprietary Information)
 
Print Name of Card Holder ___________________________________________________
 
Signature of Card Holder ____________________________________ Date ___________
If the phone was purchased within the last year, please attach a proof of purchase (Bill of Sale or Receipt showing the date of purchase and the Serial Number of the phone)
  Rev. 04/10/06
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