ORDER FORM - REQUIRED FOR ANY WORK TO BE PERFORMED


Step One - Your Information for contact and shipping:

Your Name:_________________________________________________

Address: ___________________________________________________

City:_______________________State:________  Zip:______________

Day Phone No:_____________________________Ext: _____________

Night Phone or After Hours No:________________________________

Cell Phone:_________________________________________________

eMail:______________________________________________________

Company Name (If applicable for expenses:
 

______________________________________________________________


Step Two - The device to be repaired, cost and authorization:

Manufacturer or Brand:________________________________________

Model:____________________________ Model No:_________________

Repair(s) Needed:_____________________________________________

_______________________________________________________________

Refurbished Parts OK:___________  New Parts Only______________

Estimate:______________________________________________________

Via Phone:_________________________Via eMail:__________________

Authorized by:________________________________________________


Step Three  (Shipping - See  Printing label )


AZ INDICATOR REPAIR
c/o Robert Rod
19101 Cortez Blvd.
#10249
Brooksville FL. 34603

727 - 459 - 9541




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