Other equipment in your system: ________________________________________________________________________________________________
If warranty is expired, please provide method of payment. Proof of purchase may be required to validate warranty.
PAYMENT OPTIONS
I have open account payment terms. Purchase order required. PO#: _____________________________ COD
Credit Card (Information below is required; however if you do not want to provide this information at this time, we will contact you when your unit is repaired for the
information.)
Credit card information:
Type of credit card:
MasterCard Visa American Express Discover
Type of credit card account:
Personal/Consumer Business/Corporate
Card # _______________________________________ Exp. date: ________________ *Card ID #: _______
* Card ID # is located on the back of the card following the credit card #, in the signature area. On American Express, it may be located on the front of the card. This number is required to
process the charge to your account. If you do not want to provide it at this time, we will call you to obtain this number when the repair of your unit is complete.
Name on credit card: _____________________________________
Billing address of credit card: ______________________________
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