Customer InformationName First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Daytime PhoneEvening PhoneEmail Product InformationModel of DeviceDate of Purchase Serial NumberDescribe ProblemData TransferYesNoTansfer DetailsKnown Liquid Damage?YesNoDevice UsernameDevice PasswordInitial Here*I acknowledge that service may be subject to a $100 USD diagnostic fee as described in the attached Repair Terms and Conditions, and agree that either I have made a backup copy of my data and removed any confidential, proprietary, or personal informatioti and removable media such as .oppy disks, CDs, or PC cards, or I have assumed the risk that such information or media may be lost, corrupted, or compromised during service or repair. I further acknowledge and agree that Graphicom cannot guarantee the safety, security, or integrity of any data that remains on my computer while undergoing service or repair and that Graphicom shall not be liable for any loss, corruption, or breach of such data. including any confidential, proprietary, or personal Information or removable data. By signing below, I agree that the Repair Terms and Conditions on the reverse side of this page will apply to the service of the product identified above.REPAIR TERMS AND CONDITIONS These are the Terms and Conditions governing the repair of your product by Graphicom Enterprises, Inc. (“Graphicom”). 1. Graphicom will repair your product as described and for the charges shown on the reverse side (unless such charges are revised with your oral or written consent). When the product is covered by warranty or an ex- tended service contract, such as the AppleCare Protection Plan, Graphicom will perform repairs under the terms of the warranty or the extended service contract, provided that you have presented satisfactory proof of the prod- uct’s eligibility for such repairs. You will be responsible for any additional charges applicable under your product’s warranty or extended service con- tract described on the reverse side. Including any applicable tax. 2. Unless your product is repaired under warranty or extended service contract without charge, you will pay Graphicom the amount shown on the reverse side. Your payment is due when the product is returned to you. Unless specified otherwise, the estimated amount includes all parts, labor, and certain transportation required for the repair of the product plus any ap- plicable tax. Graphicom may hold you responsible for the diagnostic fee on the reverse side, plus any applicable tax if Graphicom inspects your prod- uct, provides an estimate for you, and you do not authorize Graphicom to undertake the repairs for the estimated charges. If Graphicom determines, while inspecting your product, that repairs are needed due to failures of parts that are neither supplied by Apple nor Apple branded or are needed due to damage caused by abuse, misuse or misapplication, Graphicom re- serves the right to return the product to you without repairing it and will hold you responsible for the diagnostic fee on the reverse side, plus any applicable tax. 3. If the requested repairs require labor and/or parts not specified on the reverse side, Graphicom may seek your approval of a revised estimate. If you do not agree that Graphicom may revise the charges, Graphicom may return your product and hold you responsible for the diagnostic fee shown on the reverse side, plus any applicable tax. 4. If repairing your product under your product’s warranty or extended service contract, Graphicom may use new, used or reconditioned parts, if permitted by the terms. If repairing parts outside of warranty or extended service contract, Graphicom may use new, used or reconditioned parts. Graphicom will retain the replaced part that is exchanged under repair ser- vice as its property, and the replacement part will become your property. Replaced parts are generally repairable and are exchanged or repaired by Apple for value. If applicable law requires Graphicom to return a replaced part to you, you agree to pay Graphicom the additional cost of the replace- ment item. 5. If Graphicom repairs your product under warranty or extended service contract, the repairs will be covered solely by the terms of the warranty or extended service contract and applicable provisions of law. If your prod- uct is repaired outside of warranty, Graphicom warrants (1) that the repairs will be performed in a competent and workmanlike manner and (2) that all parts used to repair your product wilt be free from defects in materials and workmanship for a period of ninety (90) days, unless otherwise specified by Apple. Information on your product’s parts warranty may be obtained by contacting Apple at 800-APL-CARE, The warranty on parts is an express limited warranty. If a defect exists in a replacement part during the part’s warranty period, at its option. Graphicom will (1) repair the part, using new, used or reconditioned replacement parts, (2) replace the part with a new, used or reconditioned equivalent part, or (3) refund the fair market value of the part, as determined by Graphicom. THIS WARRANTY AND REMEDY ARE EXCLUSIVE AND IN LIEU OF ALL OTHER WARRANTIES, REME- DIES, AND CONDITIONS, WHETHER ORAL OR WRITTEN, EXPRESS OR IMPLIED, WITH RESPECT TO THE REPAIR PARTS. GRAPHICOM SPECIFICALLY DISCLAIMS ANY AND ALL IMPLIED WARRANTIES WITH RESPECT TO SUCH PARTS, INCLUDING, WITHOUT LIMITATION, WAR- RANTIES OF MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE. IF GRAPHICOM CANNOT LAWFULLY DISCLAIM IMPLIED WARRANTIES UNDER THIS LIMITED WARRANTY, ALL SUCH WAR- RANTIES, INCLUDING WARRANTIES OF MERCHANTABILITY AND FIT- NESS FOR A PARTICULAR PURPOSE, ARE LIMITED IN DURATION TO THE DURATION OF THE EXPRESS LIMITED WARRANTY. Some states and provinces do not allow the exclusion or limitation of incidental or con- sequential damages or exclusions or limitations on the duration of Implied warranties or conditions, so these limitations or exclusions may not apply to you. The express limited warranty on repair parts gives you specific legal rights, and you may also have other rights that vary by state or province. 6. TO THE MAXIMUM EXTENT PERMITTED BY LAW. GRAPHICOM, WILL UNDER NO CIRCUMSTANCES BE LIABLE FOR ANY SPECIAL, INDIRECT. INCIDENTAL OR CONSEQUENTIAL DAMAGES RESULTING FROM PERFORMANCE OF ANY REPAIR SERVICES, INCLUDING BUT NOT LIMITED TO LOSS OF REVENUE: LOSS OF ACTUAL OR ANTICI- PATED PROFITS (INCLUDING LOSS OF PROFITS ON CONTRACTS): LOSS OF THE USE OF MONEY; LOSS OF ANTICIPATED SAVINGS; LOSS OF BUSINESS; LOSS OF OPPORTUNITY; LOSS OF GOODWILL; LOSS OF REPUTATION; LOSS OF, DAMAGE TO, OR CORRUPTION OF DATA; OR ANY COSTS OF RECOVERING, PROGRAMMING, OR RE- STORING ANY PROGRAM OR DATA STORED OR USED WITH YOUR PRODUCT AND ANY FAILURE TO MAINTAIN THE CONFIDENTIALITY OF DATA STORED ON YOUR PRODUCT. THE FOREGOING LIMITA- TION SHALL NOT APPLY TO DEATH OR PERSONAL INJURY CLAIMS. GRAPHICOM SPECIFICALLY DOES NOT WARRANT THAT IT WILL BE ABLE TO (i) REPAIR OR REPLACE YOUR PRODUCT WITHOUT RISK TO OR LOSS OF PROGRAMS OR DATA, AND (ii) MAINTAIN THE CON- FIDENTIALITY OF DATA. IF ANY PRODUCT SHOULD BE DAMAGED OR LOST WHILE IN GRAPHICOM’S CUSTODY, GRAPHICOM’S LIABILITY WILL BE LIMITED TO THE COST OF REPAIR OR REPLACEMENT OF THE AFFECTED PRODUCT. OTHERWISE, APPLE’S LIABILITY FOR ANY AND ALL DAMAGE SHALL IN NO EVENT EXCEED THE PAYMENTS RE- CEIVED BY GRAPHICOM FOR SERVICES PROVIDED PURSUANT TO THESE TERMS. THE REMEDIES SET FORTH HEREIN SHALL BE YOUR SOLE AND EXCLUSIVE REMEDIES FOR ANY BREACH BY GRAPHI- COM UNDER THESE TERMS AND CONDITIONS. GRAPHICOM IS NOT LIABLE FOR LOSS OR CORRUPTION OF DATA OR YOUR CONFIDEN- TIAL, PROPRIETARY OR PERSONAL INFORMATION OR REMOVABLE DATA. BEFORE YOU BRING IN YOUR PRODUCT FOR ANY REPAIR SERVICE, YOU SHOULD MAKE A BACKUP COPY OF YOUR DATA AND REMOVE ANY CONFIDENTIAL, PROPRIETARY OR PERSONAL INFOR- MATION AND REMOVABLE MEDIA SUCH AS FLOPPY DISKS, CDS OR PC CARDS. 7. If you have not claimed your product and paid all charges due within sixty (60) days after being notified by Graphicom that your product has been repaired, Graphicom will consider your product abandoned. Graphi- com will provide such notice to you at the mailing address you furnished when you authorized the repairs. Graphicom may dispose of your product in accordance with applicable provisions of law, and, specifically, may sell your product at a private or public sale without liability to you. Graphicom reserves its statutory and any other lawful liens for unpaid charges. 8. If repair service involves transferring information or installing software, you represent that you have the legal right to copy the information and agree to the terms of the software license, and you authorize Apple to trans- fer the information and accept such terms on your behalf in performing the service. 9. These Terms and Conditions are governed by the laws of the State of Georgia (without giving effect to its con.ict of law provisions). If any provi- sion of these Terms and Conditions is held to be illegal or unenforceable, that provision will no longer be part of the Terms and Conditions, and the Terms and Conditions will be enforceable as though that provision never was a part of them. 10. These Terms and Conditions are the only ones that govern Graphi- com’s repair of your product. No other oral or written terms or conditions apply, including ones in any purchase order that you provide to Graphicom. No one has the authority from Graphicom to vary any of these Terms and Conditions. 11. Apple products are subject to United States and foreign export control laws and regulations, and must be purchased, sold, exported, re-exported, transferred, or used in compliance with such export laws and regulations. Initial Here*Initial that you agree to Graphicom Terms and Conditions for repair.CommentsThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.