Two Way Radio Repairs Form

Customer details

Company Name*

Contact Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email*

Enter Email Confirm Email

Phone*

Fax*

Warranty*

PROVIDED THAT THERE IS NO EVIDENCE OF PHYSICAL DAMAGE OR LIQUID INGRESS AS DETERMINED BY THE SERVICE CENTRE

Date of Purchase

Customer ID

Model No.

Serial No.

Manufacturer

Product Number

Accessories Supplied

Fault Reported

SERVICE CHARGE: $30.00 PER 15 MINUTES (EXCLUDING GST) + PARTS & SHIPPING QUOTES: $60.00 PER ITEM

Confirm*

By Ticking this box I Authorise Wireless 2-Way to complete work specified on this form. *

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