C O N T A C T     I N F O R M A T I O N

Customer Name:_____________________________________CMT CustID:___________

Company:________________________________________________________________

Shipping Address:__________________________________________________________

________________________________________________________________________

City:_____________________________________ State:_________ Zip:______________

Billing Address:__________________________________________________________

________________________________________________________________________

City:_____________________________________ State:_________ Zip:______________

Phone:__________________ Fax:__________________ Email:_____________________

P R O D U C T     I N F O R M A T I O N

Unit Model:______________ Serial Number:___________________________

Problem:_________________________________________________________________

Unit Model:______________ Serial Number:___________________________

Problem:_________________________________________________________________

Unit Model:______________ Serial Number:___________________________

Problem:_________________________________________________________________

Unit Model:______________ Serial Number:___________________________

Problem:_________________________________________________________________

Amount Authorized for Repair:__________________

Signature for Authorization:_________________________________

Payment Type:              VISA                  Mastercard                       Net 30**

**PO must be faxed or mailed with unit before CMT can authorize Net 30 terms.

Credit Card Number: ________ - ________ - ________ - ________    Exp: ____________

Cardholder's Name: _________________________________    Phone: _______________

Purchase Order # (if applicable): _______________________

NOTE: Shipping charges, duty, and taxes for the RMA order are the customer's responibility

Please fill out completely and fax to CMT at (541) 752-4117