Customer Details

First Name *

Middle Name

Last Name *

Phone *

Email *

Shop Name *

Shop Phone *

Shipping Information

Where should we ship this device once the work is complete? *
Residential Business Other

Please specify *

Where should we ship this device once the work is complete? *
Customer Shop

Address Line 1 *

Address Line 2

City *

State/Province *

Postal Code *

Country *

Product Information

Did you purchase the product new or used? *
New Used

Purchase Date *

Select Your Product *
— Select — 02 Sensor901 Series DrysuitArtic WingCCR XT w/ Trim PillowCCR XT WingClassic WingClassic XT WingClosed Bottom SMBEX35 Primary Canister LightFT1/XT2 Regulator with 28 inch HoseHP50 Handheld LightHydro Lite BCDNiTek ComputerNomad Ray Sidemount SystemNomad XT Sidemount SystemO2ptima BMO2ptima CMOpen Bottom SMBParmasoft 905 EXPRec SeriesRec XT WingSingle Tank TransPlate PackagesTravel WingTravelPac BCDVoyager WingXT1/XT2 Regulator with 28 inch HoseXT1/XT4 Regulator with 28 inch HoseXT4 Second StageFT1/XT2 Basic Open Water Regulator PackageFX40 Handheld Primary LightGX40 Handheld Primary LightLX20+ Handheld Primary LightSingle Tank TransPac PackagesXT1/XT2 Basic Open Water Regulator PackageXT1/XT4 Basic Open Water Regulator PackageXT2 Second StageCX2 Handheld LightCX3 Handheld LightFT1/XT2 Advanced Open Water Regulator PackageVoyager SeriesXT1 First StageXT1/XT2 Advanced Open Water Regulator PackageXT1/XT4 Advanced Open Water Regulator PackageBX2 Handheld LightFT1 First StageFT1/XT2 Deco/O2 RegulatorTravel SeriesXT1/XT2 Doubles Regulator PackageXT1/XT4 Doubles Regulator PackageO2 Deco RegulatorXT1/XT2 Sidemount Regulator PackageXT1/XT4 Sidemount Regulator PackageNo Mount Tank BCTransPac Harness

Serial Number

Number of Dives on Product *

Is this used for teaching and/or rental? *
Yes No

Have we serviced this before? *
Yes No

If yes, when? *

Issue & Attachments

Please Describe The Issue: *

Upload Images of the issue/damage

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Final Confirmation

I accept the terms and conditions of repair service by Dive Rite *