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 — 901 Series DrysuitArtic WingBX2 Handheld LightCCR XT w/ Trim PillowCCR XT WingClassic WingClassic XT WingClosed Bottom SMBCX2 Handheld LightCX3+ Handheld LightEX35 Primary Canister LightFT1 First StageFT1/XT2 Advanced Open Water Regulator PackageFT1/XT2 Basic Open Water Regulator PackageFT1/XT2 Deco/O2 RegulatorFT1/XT2 Regulator with 28 inch HoseFX40 Handheld Primary LightHP50 Handheld LightHydro Lite BCDLX20+ Handheld Primary LightNiTek ComputerNo Mount Tank BCNomad Ray Sidemount SystemNomad XT Sidemount SystemO2 Deco RegulatorO2ptima BMO2ptima CMOpen Bottom SMBOxygen SensorParmasoft 905 EXPRec SeriesRec XT WingSingle Tank TransPac PackagesSingle Tank TransPlate PackagesTransPac Harness OGTravel SeriesTravel WingTravelPac BCDVoyager SeriesVoyager WingXT FinsXT1 First StageXT1/XT2 Advanced Open Water Regulator PackageXT1/XT2 Basic Open Water Regulator PackageXT1/XT2 Doubles Regulator PackageXT1/XT2 Regulator with 28 inch HoseXT1/XT2 Sidemount Regulator PackageXT1/XT4 Advanced Open Water Regulator PackageXT1/XT4 Basic Open Water Regulator PackageXT1/XT4 Doubles Regulator PackageXT1/XT4 Regulator with 28 inch HoseXT1/XT4 Sidemount Regulator PackageXT2 Second StageXT4 Second Stage

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

---

Final Confirmation

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