Wireless 2 Way Repairs Form Wireless 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 CENTREYesNoDate of Purchase 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 This iframe contains the logic required to handle Ajax powered Gravity Forms.
