Form

	Your Contact Information


First Name *
Last Name *
E-mail *
Phone
Address *
City *
State
Non-US State/Province
Postal Code *
Country *

	Your iPod Information


Model *
Serial Number
Passcode (if applicable)
Problem(s)	Cracked Screen/Defective Screen Decreased Battery Life Audio Jack (No Sound) Click Wheel Cosmetic/Panels (Scratches/Dents) Hard Drive (Sad Face, Clicking Noises) Don't Know
Description of Problem or How Damage Occured
Add-Ons (Prices Valid only With Repair)	New Battery - Add $19 New Earphones (Genuine Apple)- Add $19

	Payment and Shipping Information


Referral/Coupon Code (if applicable)
Payment Method (No Payment is Required until Repair is Complete) *	Credit Card (via Google Checkout) PayPal Personal Check/Money Order
Return Shipping Method *	FedEx Ground/Home Delivery (2-4 bus. days) - $0 FedEx Express Saver- add $21 International (See Surcharge List)
May we complete repairs under $65 without your authorization? *	Yes No

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