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
CUSTOMER:                    Date: ______________      PO#: _______________
Company Name
(for aircraft maintenance centers):   _____________________________________ Your Name:  ___________________________________________________
  Shipping Address (line 1): _______________________________________
  Shipping Address (line 2): _______________________________________
  City:_______________________ State:_________ ZipCode:___________
  Country:____________________ Phone:_________________________
  Fax:___________________ E-mail:_____________________________

PAYMENT by:   __C.O.D.   __Check    __Call For Payment   __Credit Card*:
*Credit Card Number: ________________________________________Expiration_________CVV_______
Credit Card Billing Address:    (If same as shipping address, check here [_]. )
  Billing Address: ____________________________________________________
   City:________________________ State:_____________ ZipCode:__________

SHIPPING:     ___GROUND     ___2-DAY     ___OVERNIGHT     ___CALL WHEN DONE

INSTRUMENT INFORMATION:
INSTRUMENT #1

Model #:

Part #:
Serial #:
Purchase Date:
Description of problem:

 

INSTRUMENT #2

Model #:

Part #:
Serial #:
Purchase Date:
Description of problem:

 

 
 
 

Please print, fill in blanks as needed, and send with your instrument(s).