Repair Form

Please print this entire form and send it with your product to the address below.

(Information entered into this form will not be collected or stored by United Camera Repair, Inc. at this time.

Please send this form to the address below for processing.)


First Name:

Last Name:



Cell Phone:



Company Name:

Address 1:



Address 2:





Zip Code:









Diagnostic Fee: $




Serial #:






A Check for the Diagnostic Fee is enclosed

Credit Card

Please bill my Credit Card for the Diagnostic Fee


Please Repair if the cost is at or below: $ Notify me if costs exceed this amount


  Please call for Credit Card Information.

Name on Card:

Card Type:

Number on Card: 

Expiration Date:


3 Digit Validation Code (on back of card)



Send Product to:

United Camera Repair, Inc.

3830 14th Avenue

Rock Island, IL  61201

Please ship your product via a carrier service with a means of tracking your package.  Insure all shipments and please

keep a record of the tracking number and product serial number in the event you must trace the package.

United Camera Repair, Inc. will not assume responsibility for loss and/or damage during transit.

If you have any questions please contact United Camera Repair, Inc. at 1-(309)-786-0950