Duclos Equipment Intake Form

1
Contact Name* This field is required.This is the person we'll associate with your order and contact with follow-up details.
First Name
Last Name
2
Company Name
3
Email* This field is required.
example@example.com
4
Phone NumberExample: +1 818-773-0600 (no extensions or alternate numbers)
5
Phone Number* This field is required.Example: +1 818-773-0600 (no extensions or alternate numbers)
Area Code
Phone Number (NO EXTENSIONS)
6
Billing Address* This field is required.This is the address we'll use for billing. We'll collect a separate Shipping Address in the next section.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
United States
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
7
Type of work* This field is required.Are you sending in your equipment for service/repair or are you sending in lenses to receive the Cine-Mod treatment?
Service
Cine-Mod®
8
Service+ Maintenance Program?Check this option only if you're sending your lens in for maintenance covered under our Service+ Maintenance Program. If you're not sure, please contact your Duclos Sales representative.
Service+
9
Equipment List* This field is required.IMPORTANT! Use as many lines as you need for each item but please be sure to use a new line for each item or lens you're sending in. We'll collect the repair/mod requests and notes for your items in the next section. List Format: "Serial Number" "Make" "Model" "Focal Length" "Speed" Example: #123456 Zeiss Super Speed35mm T1.3 Example: #1234 Heden M21VE-L Motor
Format: "Serial Number" "Make" "Model" "Focal Length" "Speed" | Example: #123456 Zeiss 35mm T1.3 Super Speed
10
Notes* This field is required.IMPORTANT! Read the instructions carefully. FOR SERVICE: Summarize the issues you'd like addressed or the adjustments you'd like made. FOR CINE-MOD: Detail the modifications you'd like applied to your lens(es).
Be detailed with the services you'd like to so that we can generate your estimate promptly..
11
Incoming Logistics* This field is required.Let us know how would plan to get your equipment to us so that we can plan accordingly.
Ship
Drop-Off
12
Outgoing Logistics* This field is required.Choose an option for return logistics. - Ship: Domestic shipments are shipped via FedEx 2-Day (signature required). - Ship: International shipments are shipped via FedEx International Economy. - Pick-Up: We'll reach out when the job is complete to arrange pick-up details. - Contact Me!: We'll reach out once the job is complete to arrange details.
Ship
Pick-Up
Contact Me!
13
Return Shipping AddressThis is the address we'll use to ship your equipment back to you once the work is complete. SEE NOTES BELOW! - Type "SAME" in the first line if the Return Address is the same as the Billing Address you entered previously. - Type "CONTACT" if you're not sure where you'd like it shipped and our team will contact you before shipping.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
United States
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
14
Rush Service?* This field is required.We offer a RUSH service for customers that require expedited repairs/mods. Typically a rush fee of 25% for Service labor or $50/lens for Cine-Mod work is incurred. Let us know if you'd like to add a rush service to your order and we'll reach out once we've received your equipment to discuss further.
No
RUSH!
15
Date
Date
Month
Day
Year
16
Terms and Conditions* This field is required.Service estimates are provided at no cost to the customer if any/all recommended work is accepted and approved. If a service estimate is prepared and all work is declined, a fee will be charged. Response time can vary and is not guaranteed. Turn-around time depends on current workload and other factors. Please be sure to package your lenses properly - Duclos Lenses is not responsible for damage to incoming equipment as a result of carrier or shipping mishaps. For international shipments, please consult your local shipping service to determine best practices. Duclos Lenses is not responsible for import or export taxes, duties, or fees. Any charges incurred as a result of shipping are the responsibility of the customer. Service and repair orders are addressed on a first come first serve basis at time of equipment arrival. Duclos Lenses may publish photos, video, or written content about customers lenses from time to time. However, personal information is kept strictly confidential. If you have questions, feel free to contact Duclos Lenses at any time. http://duclos.tv/contact
I have read and agree to the Terms and Conditions above.
17
How did you hear about us? (optional)Let us know how you heard about Duclos Lenses so that we can improve our efforts.
Please Select
Please Select
Word of mouth
Google Search
Facebook
Instagram
YouTube
User Forum
LinkedIn
Other
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