REMOTE REPAIR ORDER FORM

Name: _______________________________________

Business name (opt): ______________________________________________

Address: _________________________________________________________

City/State(prov.): _______________________________________________

ZIP/Country: ____________________________________________________

Email: _______________________________________________________

Phone/Fax: _______________________________________________________

Payment Method

If paying by Check/Money Order please provide check number here: ___________

or if paying by Credit/Debit Card

Circle One: Visa | Mastercard | American-Express | Discover

Credit Card #: ___________ ____________ _____________ _____________

Expiration Date: ____________________ CCV Number*: __________

(*3 digit number on back if using Visa, Mastercard or Discover. 4-Digit number on front of American Express)

Signature for credit card orders:_______________________________

Repair Information
REMOTE BRAND: ___________ REMOTE NUMBER: ___________ UNIT MODEL NUMBER: ___________


PROBLEM WITH REMOTE

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SPECIAL INSTRUCTIONS

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Standard Remotes $23.00 [_] Special Remotes $33.00 [_]
Special Remotes consist of multiple circuit boards or slide switches.

Not sure send $33.00 and we will refund the difference.
for more information see www.theremotedoctor.com
Price includes shipping

TOTAL AMOUNT- $___________ ENCLOSED

Mail this form and remote(s) to:
REPLACEMENTREMOTES
4945 Reynolda Road
Winston-Salem, N.C. 27106
or
CALL 1-877-671-7173