TMDE Information Form

Contact information

Department Name:

Address:

Address 2:

City: State: Zip Code:

Contact (For returning items to):

Email:

Phone Number: Fax Number:

TMDE policy is to repair, invoice and ship all jobs that are under $150 without prior estimates. Declined repairs are subject to minimum evaluation and shipping fees.
If you would prefer us to contact you prior to performing the repair, please check the box below.

Require estimate and get approval prior to repair.

Please enter your PO number or enter "none" and check the box below verify that you do not need one prior to submission of this repair.

P. O.: Our department does not require purchase orders.

Product Information

Please fill in the following to let us know about the item you will be shipping to us.

Manufacturer:

Model:

Serial Number:

Unit under warranty?

Yes
No
Unsure

Description of the Problem:

Shipping Information:
Please state everything you are including with the unit. If sending multiple units, you must include every serial number.

Billing information (Contact information required)

Billing Contact (For receiving invoices/accounts payable):

Billing Email:

Billing Phone Number:

Billing Department Name:

Billing Address:

Billing Address 2:

Billing City: Billing State:

Billing Zip Code:

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