389 Johnnie Dodds Blvd. Suite 113
Mount Pleasant, SC 29464 U.S.A.
ph. 877.336.8259 / fx. 843.884.3325
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Item Make
Serial #
Repair as Needed
Estimate
Warranty
1)
Make Your Selection
Bein Air
Dabi Atlante
Dentex
HealthCo
Impact Air
Kavo
Kinetic
Lares
Micro Motors
Midwest
MTI
NSK
SafeCo Excel
Siemens
Star
W&H
Other
2)
Make Your Selection
Bein Air
Dabi Atlante
Dentex
HealthCo
Impact Air
Kavo
Kinetic
Lares
Micro Motors
Midwest
MTI
NSK
SafeCo Excel
Siemens
Star
W&H
Other
3)
Make Your Selection
Bein Air
Dabi Atlante
Dentex
HealthCo
Impact Air
Kavo
Kinetic
Lares
Micro Motors
Midwest
MTI
NSK
SafeCo Excel
Siemens
Star
W&H
Other
4)
Make Your Selection
Bein Air
Dabi Atlante
Dentex
HealthCo
Impact Air
Kavo
Kinetic
Lares
Micro Motors
Midwest
MTI
NSK
SafeCo Excel
Siemens
Star
W&H
Other
5)
Make Your Selection
Bein Air
Dabi Atlante
Dentex
HealthCo
Impact Air
Kavo
Kinetic
Lares
Micro Motors
Midwest
MTI
NSK
SafeCo Excel
Siemens
Star
W&H
Other
Pickup Information
I will ship myself. (Print out the
Free US Postage Paid Business Reply Label
)
UPS Next Day (Label will be faxed or emailed)
Fax
Email
Additional Comments
Please Print out two copies of this form:
1) For your records
2) To include with repair package
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