Please print out two (2) copies of this form, keep one (1) copy for your records and send one (1) with your shipment. Video One Repair 501 South Reino Road, Suite I #127 Newbury Park, CA 91320 (888) 283-2228 email@example.com www.VideoOneRepair.com NameCompanyAddressApt./SuiteCityUS StateZip/Postal CodeEmail Home PhoneWork PhoneCell PhoneBrandModelSerialPlease describe the problem you are experiencing:Can't print this form? If you don't have a printer or are unable to print this form, don't worry -- it's not required. Just write your information on a piece of paper and include it with your camcorder.Questions? Call Us 1-888-283-2228NameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.