QuintilesIMS Mail-in Individual Repair Request Form Welcome! Please complete this form if you have a business phone you need to mail-in for repair. This form is for employees who will be expensing the cost, not applying the cost to the open PO (which needs authorization). Questions? Feel free to explore our website or email email@example.com any time. Thank you for repairing with TCR: Triangle Cellular Repair! Your Name* First Last Phone Number (needed to process payment over the phone)*Email (shipping label sent here)* Enter Email Confirm Email Return Mailing Address - where fixed phone(s) will be sent* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code What type of device(s) need repair? How many of each type?*Please list each type of device you are sending and the total quantity per type. For example: iPhone 6 x2, iPhone 6+ x3, iPhone 6S+ x1. What needs to be fixed on the device(s)?* Cracked glass and/or LCD Buttons Camera(s) Charge Port or Headphone Jack Microphone or Speaker(s) Other If "other" above, please describe device(s) and quantity of eachAre the defects labeled on each phone? This is required for faster processing, thank you!*YesNo, I'll do that now!When would you ideally have the fixed devices back in your hands?*How will you be paying for this repair? Authorization is required if you are using the company PO. If you are using a credit card, we will call you to process payment over the phone after completing the repair.*Anything else to add or ask?