Grip-Rite Service Payment Form

Date (ex. 2/22/2012) Email Claim Form Number

Place of Purchase Purchase Date Date unit Failed

Service Center Name PrimeSource Account Number

Address City State Zip

Contact Name Phone Fax

Customer Name Phone

Model Number Serial Number

Qty	PS Part #	Description	PS Inv #	Dealer Price	Total
Total Parts:
Add 15% to parts cost for handling:
Labor Hours:				X & 30/HR =
Freight Only:
Total Claim Amount:

Technician: I certify, I have performed the services & installed the parts listed above.
Technician Signature:		Date:
Customer Signature:		Date:

State problems with tool or compressor: