Pump Repair Authorization

Name *

First

Last

Company

Your Company Name

Phone Number *

Your Phone Number

Email *

Best Email for Contact

Address

Address Line 1

Address Line 2

City

State

Zip Code

Your Company Location - Ship To Address

Checkbox Items *

Warranty Repair
Non-Warranty Repair

Please Select One for Your Repair - WARRANTY REPAIRS REQUIRE INVOICE FROM ORIGINAL PURCHASE

File Upload

Click or drag a file to this area to upload.

Please Attach Original Invoice If Warranty Repair

Drop Off/Ship To Date (Our Location)

Date

Time

Date Required for Pump Return

Date

Time

Call With Estimate *

Authorization For Pump Repair Estimate

I hereby request Lubromation Inc. to contact me with a written repair estimate on my equipment. Estimate charges are: $10.00 for Hand-Held Items $30.00 for grease or oil pumps, reels and other lubrication components $100.00 for any Ink Pump or pressure primer assembly

Date of Authorization *

Date

Time

Repair Equipment Not to Exceed (Optional)

I Hereby authorize Lubromation Inc. to repair my equipment with total labor and material charges not to exceed the below listed amount. Please contact me when my equipment is readyfor pickup or shipping

Total Amount for Pre-Authorized Repair (Optional)

Amount You Authorize Lubromation Inc. To Repair Equipment For (Not To Exceed)

Charge Repairs To *

My Customer Account (Please List Account Number In Notes Sections If Available)
Credit Card Payment
Cash

Your Payment Type For Repair

Notes - Equipment Issues *

Customer Notes - Equipment Issues