Advanced Replacement RMA Approval Form

"*" indicates required fields

RMA Number*

RMA Type*

Account*

RMA Items*

Part Number

Quantity

Serial Number

List Price

Item Total*

This amount will be charged at the end of the RMA window if the above items are not returned.

For FasCard Touch Kiosks the swap out price is the base price. One the kiosk is returned CCI will assess the repairs needed and provide a final cost.

Swap Out ID

Swap Out Price

Only Ground shipping is covered by CCI.

Shipping Address*

Shipping Method*

Shipping Total*

Due Now*

Credit Card*

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Billing Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Approved By*

First Last

Email*

Enter Email Confirm Email

Purchase Order #*

If unable to provide a proper PO you can enter "verbal" with your initials (ie. Verbal ABC).

Signature*