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REPAIR & SERVICE REGISTRATION

REPAIR REGISTRATION FORM

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Email *

IEM INFORMATION

Do you have a serial N°? *

YES, AS BELOW
NO

SERIAL N°

Model *

Custom (CIEM)
Universal (UIEM)

AFFECTED CIEM *

RIGHT SIDE - CIEM
LEFT SIDE - CIEM

AFFECTED UIEM *

RIGHT SIDE - UIEM
LEFT SIDE - UIEM

CLEANING (CHF 80.00) *

SERVICE LEVEL 1 - (filters replacement, cleaning, testing) - CHF 80.00
OTHER DEFECT (please describe below, separate invoicing)

RIGHT SIDE ISSUE - CIEM

IEM FITTNG
CABLE ISSUE
IEM CONNECTOR
SOUND DEGRADED
NO SOUND
SHELL BROKEN

RIGHT SIDE ISSUE - UIEM

CABLE ISSUE
IEM CONNECTOR
SOUND DEGRADED
NO SOUND
SHELL BROKEN

LEFT SIDE ISSUE - CIEM

IEM FITTNG
CABLE ISSUE
IEM CONNECTOR
SOUND DEGRADED
NO SOUND
SHELL BROKEN

LEFT SIDE ISSUE - UIEM

CABLE ISSUE
IEM CONNECTOR
SOUND DEGRADED
NO SOUND
SHELL BROKEN

PLEASE PRINT THIS FORM AND IDENTIFY THE AREA WHICH NEED TO BE ADAPTED. ADD ANY FURTHER HELPFUL COMMENT. FITTING CLAIM - REPAIR ANNEXE I

RIGHT SIDE - DEFECT DESCRIPTION

LEFT SIDE - DEFECT DESCRIPTION

File Upload

Click or drag files to this area to upload. You can upload up to 4 files.

Image: .png, .gif, .jpg / Documents: .doc, .xls, .ppt, .pdf / Video: .mpg, .mov, .wmv / 5Mo per file MAX

REPAIR AGREEMENT *

PLEASE PROCEED TO THE REPAIR. ALL ADDITIONAL COSTS WILL BE COVERED AND ASSUMED WITHOUT THE NEED FOR A QUOTE
PLEASE SEND ME A QUOTE IF THE TOTAL COST OF THE REPAIR EXCEEDS THE AMOUNT OF CHF 80.00
PLEASE SEND ME A QUOTE FOR ACCEPTANCE BEFORE ANY REPAIR

SHIPPING ADDRESS

P-EAR-S Sàrl

Chemin des Jardinets 7

2034 Peseux

Switzerland

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