Affiliate Warranty Parts Request

Company Name*
Contact Name*
First Last
Date
MM slash DD slash YYYY
Ship to Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
ATM Information
ATM Model #*
ATM Serial #*
Terminal #*
Part #*
Part Serial #*
Part Description*
Error Codes
Description of Problem*
Shipping Method*
- Ground (No Charge)
- Overnight (Fee)
Defective part must be returned to the manufacturer within 14 days of receipt of replacement or your credit card will be charged.
Payment
Warranty will not be processed without credit card payment information completed. Please call Empire at 1-866-88-EMPIRE (36747) to finish this process. Allow 24 hours for processing.
Signing this form permits Empire ATM Group to charge your account for costs incurred due to affiliate not returning parts to the manufacturer in the agreed upon timely manner.*
- I understand

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ATM Information