Aircraft Quality Instruments, Inc.
2649 S. Custer
Wichita, KS 67217
USA
Phone: (316) 942-9933 - Toll Free: (800) 942-9938
Fax (316) 942-9975

REQUEST FOR SERVICE

Date___________________
Company Name (for aircraft maintenance centers):
___________________________________________________
Your Name:_________________________________________
Shipping Address:____________________________________
Shipping Address_____________________________________
City___________________State:__________ZipCode_______
Country_______________ Phone:_______________ Fax_________________Email_____________________

Payment by:
C.O.D __ Check __ Credit Card__ Call For Payment __
Credit Card Number: ________________________Expiration_________CVV_______
Credit Card Billing Address
(If same as shipping address check here [ ]. )
______________________________________
City_______________State_______Zip________

How quickly do you want this shipped back to you?
GROUND___ 2DAY___ OVERNIGHT___ CALL WHEN DONE___

INSTRUMENT INFORMATION
Model No:________________ PartNo:____________________

Serial No:_____________________Purchase Date___________

Description of problem:

Please complete fields as needed, and send with your instrument.