Inter-M AMERICAS

13875 Artesia Blvd. Cerritos, CA 90703
Tel 562-921-0313
Fax 562-921-0370

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Out of Warranty Service Request
Company Name:
First Name:
Last Name:
Email Address:
Invoice Number:
Purchase Date:	YYYY-MM-DD
Purchased From:
Serial Number:
Model Number:
Street Address:
City:
State:
Zip:	00000
Phone Number:	000-000-0000
Problem Description: