The Towne Cobbler - Merchandise Repair Form

The Towne Cobbler Shoe Repair Service
John Ambolino, Proprietor
139 North West End Blvd
Quakertown, PA 18951

MERCHANDISE REPAIR FORM

Print and complete this repair form
and include with item being repaired.
Select describe the item being sent in for repair
and what repair is needed.
To discuss repair or to receive an estimate
please call 215-536-6858

Please describe Item being returned:

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______________________________________________________________________

Please describe repair required:

_____________________________________________________________________
_____________________________________________________________________
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Cost of Repairs (Initial to right):

Based on the following:	Ok to proceed with repair (Sign below)
Repair has been estimated at $ _____.__
I approve the repair up to a cost of $ ______.__.
Please call me with cost before starting repair.

Contact Information - repaired item to be shipped back to:

Name:
Address:
City / State / Zip Code:
Phone:	Home ____ Work ____
Phone (Fax):
EMail Address:

Please credit or charge my Account: Visa Mastercard

Account # _________________________ Expiration: _____/_____ CSV Code _______

If the name and / or address on card is different from ship to address above, please complete:

CC Bill To Name:
CC Billing Address:
City / State / Zip Code:

Signature: ________________________________