Industrial Electronics Repair Service Form IER

Please copy and/or print the following form using your browser. 
Fill in the information, and enclose this form with your items for repair. 

Company     ____________________________________

Your Name  _____________________________________

Department _____________________________________

Address      ___________________________________

City/State/Zip _________________________________

Your PO#    ____________________________________

Phone & Fax      _______________________________

Email         __________________________________ 

Model Number ___________________________________

Serial Number __________________________________

Description ____________________________________

Problem ________________________________________

Please attach any schematics, hook-up diagrams, or manuals you may have. 
Also, units that use custom software 
please include a copy of the software if possible. 
The more information you provide us, 
the faster and cheaper we will be able to repair your unit. 

For faster turn around.

Repair Approval Amount _________________________

Approval Signature _____________________________

Thank you!
Send To:

Industrial Electronic Repair
Marty A Lineberry
266 Northstar Dr. Suite 136
Rural Hall, NC 27045
1-(336)-969-0110

Questions: Contact Us