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*
Equipment details
Warranty*
PROVIDED THAT THERE IS NO EVIDENCE OF PHYSICAL DAMAGE OR LIQUID INGRESS AS DETERMINED BY THE SERVICE CENTRE
- Yes
- No
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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Customer details