Please print, complete in pen, and send to:
Rainy Pass Repair, Inc.
4415 Stone Way North
Seattle, WA 98103
REPAIR FORM
NAME:______________________________________________________________________
EXPIRATION DATE:____________ CCV (last 3 digits on back of card):______
AUTHORIZED AMOUNT (Please allow for 20% over estimate and for return shipping):______________________
NAME AS IT APPEARS ON THE CARD:______________________________________
AUTHORIZED SIGNATURE:________________________________________________
ADDRESS:___________________________________________________________________
CITY:_______________________________________ STATE:__________ ZIP:____________
E-MAIL ADDRESS:____________________________________________________________
DAY PHONE: ________________________________________________________________
DESCRIPTION OF ITEM:_______________________________________________________
DESCRIPTION OF DAMAGE:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
DESCRIPTION OF WORK TO BE COMPLETED:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
ESTIMATE GIVEN (Estimates are not quotes and may not include shipping.):
Repair:___________________Shipping:____________________Call me with estimate
SPECIAL INSTRUCTIONS (alternate color choices, date needed by, etc.):
________________________________________________________________________
________________________________________________________________________
WARRANTY/BILL TO:____________________________________ RA#_____________
CHECK/MONEY ORDER: CREDIT CARD:
CREDIT CARD NUMBER:_____________________________________________________