TAYMAN ELECTRICAL

 For your convenience, you may print this form, fill it in, and include it with your radio.

Name: _______________________________________________________________

Address: _____________________________________________________________

City, State, ZIP: ________________________________________________________

Phone: ________________________ E-Mail: ________________________________

Year & Make of Car: _______________________________________________

Voltage: ______________ Polarity: __________________

If payment by Credit Card:

Visa, MC, Disc: ________ ________ ________ ________ Exp: __________ Code:________

Is billing address same as above? If different, Street #: __________ ZIP: __________

 

Service/Product requested:

_______ Repair/Restoration of Original AM Radio

______ AM/FM Stereo Conversion

Other request or special instructions: _______________________________________

______________________________________________________________________

 

For Office Use Only:

Date Received: __________________ Condition: ____________________________ Model #: _____________

 Notes: _____________________________________________________________________________________