PocketWizard™ Repair Form

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Ship prepaid and insured to:
PocketWizard^T Professional Division
Mamiya America Corporation
8 Westchester Plaza, Elmsford, NY 10523
Phone: 914-347-3300 Fax: 800-321-2205

YES! I hereby pre-approve a repair estimate of $_______. If the charge is higher, contact me before proceeding.

Ship U.P.S. to the address below via:
Ground @ $15 3rd day air @ $25 2nd day air @ $30 Next day air @ $40

I hereby request expedited service at an extra charge of $30 (telephone in advance to make these arrangements).

Name
Company
Address
City / State / Zip
Telephone / Fax
Method of Payment: Check Amex Visa MasterCard
Account No.
Expiration Date
Name on Card
Signature / Date

Please include a letter with a thorough explanation of the problem or service to be performed. List each item, with serial numbers included in this shipment.