Name:

Instructions:
1 - Enclose this form for easy identification.
2 - Label reels with corresponding reel #.
3 - If you do not remove the line from your reels, ------please tape the whole way around the spool

------with masking tape.

Address:

City:

State:

Zip:

Phone:

Cell:

Check if you want to be notified

before any addl repairs over $20

Email Address:

Reel #1 - Make and Model:

Reel Condition, Issues, Noises, Etc:

Reel #2 - Make and Model:

Reel Condition, Issues. Noises, Etc:

Reel #3 - Make and Model:

Reel Condition, Issues. Noises, Etc:

Standard Cleaning $17.50/Reel

(Lmtd time only)

Extra Svc Chg - Dis- or Mis-assembled, Really Dirty

or High-End reels

(call or e-mail for estimate)

Part:

Part:

Part:

Part:

Part:

Tax:

(sorry, but Va. says if I install the parts here, I must collect sales tax)

Sub Total:

Estimated S&H 1st Reel $7.50

Estimated S&H each additional reel $2.00

Postal Insurance - Will be added unless declined

Declared Value (enter 0 to decline):

$

Total:

*** Actual Shipping Charges will be applied when they exceed the above amts.

Date Received:

Please makes checks payable to:

Date Shipped:

Dominion Tackle, LLC

Tracking Number:

© 2008 Dominion Tackle, LLC