SHIPPED FROM INFORMATION

COMPANY:

CONTACT NAME:

ADDRESS:

CITY                      STATE                    ZIP

PHONE                            FAX

SHIP TO:                  SAME AS SHIP FROM

COMPANY:

ATTN:

ADDRESS:

CITY                      STATE                    ZIP

PHONE                            FAX

BILLING INFORMATION:

***JUNE COMPANY ACCEPTS MC, VISA, AMEX, COMPANY CHECKS, COD AND ELECTRONIC/WIRE TRANSFERS FOR ALL REPAIRS FOR THE FIRST SIX MONTHS OF BUSINESS FOR NEW CUSTOMERS.

PAYMENT VIA:

MC    VISA      AMEX     COMPANY CHECK    COD       ELECTRONIC/WIRE TRANSFER    NET 30***

FULL NAME ON CARD:

CREDIT CARD #

EXPIRATION DATE:

CC BILLING ADDRESS                                                                           SAME AS SHIP TO:  

MANUFACTURER:

MODEL / PART #

DESCRIPTION OF UNIT:

SERIAL #:

DESCRIPTION OF PROBLEM WITH UNIT:

JUNE COMPANY USE:

REPAIR COST $

INITIAL ANALYSIS: