Warranty Parts Order 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.
Component Name
Serial Number
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:
Ship Parts To:
Location Name:
Address:
Address 2: (optional)
City:
State:
Zipcode:
Contact:
Contact Phone No:
Shipping Method (Priority and Saturday Delivery; there will be a charge of $25.00)
Next Day Afternoon Delivery Before 3 pm (No charge). Warranty parts only!
Please note you are responsible for freight charges of parts returned to Qualtex.
Next Day Delivery before 3PM (no fee)
Priority Overnight ($25.00 Fee)
Priority Saturday Delivery ($25.00 fee)
ALL PARTS TESTED AND “NO PROBLEM FOUND” ARE SUBJECT TO CHARGES AND DENIAL OF WARRANTY CLAIM.
