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*= Required Fields

Number used by service center for record control: *
(This number cannot be used previously on a claim form.)

SERVICE CENTER
NUMBER: *
NAME: *
ADDRESS: *
CITY: *
STATE: *
ZIP: *
COUNTRY: *
E-MAIL: *
CUSTOMER
NAME: *
ADDRESS: *
CITY: *
STATE: *
ZIP: *
COUNTRY: *
PRODUCT INFORMATION
PRODUCT MODEL: *
PRODUCT SERIAL NUMBER: *
PRODUCT DATE CODE: *
PRODUCT PURCHASE DATE: *
SERVICE INFORMATION
DATE SERVICE REQUESTED: *
DATE SERVICE PERFORMED: *
REPAIR TIME (HOURS): *
SHIPPING COST: optional (U.S & Canada Only)

 

Required Information:

Selected Symptom Codes:

Selected Failure Codes:

Available Symptom Codes:
(double click symptom to add to list above)

Please include any additional
information to describe the symptom(s):
 
 

optional

Available Failure Codes:
(double click failure to add to list above)

 

DESCRIBE SERVICE PERFORMED: *
NOTE ANY MANUFACTURING DEFECTS: optional
COMMENTS: optional

 

QUANTITY
*
JBL PART #
*