Broken Screen Replacement Form
THIS IS AN ELECTRONIC FORM, PLEASE FILL IN ELECTRONICALLY.
Enter 7-digit Store Number (required field)
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Store Information
Business Unit
Region
Mkt/Dist
Store Type
Brand Signage
Street Address
City
State
Zip Code
Phone Number
email
Describe Your Issue
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ex. Broken screen, Brightsign player not working.
Screen(s) Application
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ex. Car Wash, Ad Wall, Menu, Coffee, etc.
Type Of Screen(s) or Mediaplayer
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(e.g., Samsung, LG, BrightSign etc.)
# Of screens In The Total Setup Broken/Not Working
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Screen(s) Model # (Can Be Found On Back Of The Screen(s)
Size Of Screen(s) In Inches (Please Measure To Help Speed Our Process Up)
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What Kind Of Mount/Mounts Are Being Used
Do You Need New Mounts - If Yes, How Many?
Please Select
Comments
Photos
Photo Of Nameplate(s) of Affected Screens / Mediaplayer - This typically includes the serial number, model number, and manufacturer info.
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Upload / Take Photos
Please Include a Photo For Each Screen
Cancel
of
Photo Of Full Screen Setup - Please include a photo of all screens in group from a distance taken from the front view.
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Submitter Name
*
First Name
Last Name
Date
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Your Email
*
example@example.com
Submit
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