Non-Warranty Parts Ordering and Non-Warranty Repair Request Form
This form must be completed and sent 2:00pm C.S.T for same day shipment.
Date
Distributor
Phone Number:
Contact Name:
Email Address:
ATM Serial Number:
ATM Phone Number:
RMA Number:
(Issued by Qualtex)
Please enter the serial number to the component being sent for repair or inspection. Also, check the box indicating whether the part is for repair or inspection. If purchasing a new part, please enter the quantity in appropriate box under "Purchase New" column.
Component Name
Serial Number
Repair
Inspection
Purchase New
Front Screen/Keypad Module
Rear Screen/Keypad Module
Printer Module
2400 BPS Modem
Power Supply
Card Reader
Dispenser
E-lock
Other - Specify in Serial Number field
Error Code(s)
Detail the Problem:
Check here if you would like to be notified of repair cost prior to repair. Please note a component diagnostic fee of $50.00 will be charged if you elect NOT to repair the part. If no box is x, the part will be repaired automatically.
Ship Parts To:
Bill Parts To:
(leave blank is same as shipping)
Location Name:
Corporate Name:
Address:
Address:
Address 2: (optional)
Address 2: (optional)
City:
City:
State:
State:
Zipcode:
Zipcode:
Contact:
Contact Phone No:
Please note you are responsible for all freight charges. Please select your preferred shipping method by checking a box below.
If shipping method is not selected the service department will ship via ground delivery service.
Ground
Second Day
Priority Overnight
Priority/Saturday
