Wireless 2 Way Repairs FormWireless 2 Way Repairs Form Customer detailsCompany Name*Contact Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email* Enter Email Confirm Email Phone*Mobile*FaxEquipment detailsWarranty*PROVIDED THAT THERE IS NO EVIDENCE OF PHYSICAL DAMAGE OR LIQUID INGRESS AS DETERMINED BY THE SERVICE CENTRE Yes NoDate of Purchase DD slash MM slash YYYY Customer IDModel No.Serial No.ManufacturerProduct NumberAccessories SuppliedFault ReportedSERVICE CHARGE: $30.00 PER 15 MINUTES (EXCLUDING GST) + PARTS & SHIPPING QUOTES: $60.00 PER ITEMConfirm* By Ticking this box I Authorise Wireless 2-Way to complete work specified on this form. *CAPTCHA
