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Name: _____________________________________________________________________
Company Name: _____________________________________________________________
Address: ___________________________________________________________________
City, State, Zip: ______________________________________________________________
Phone 1: ______________________________ Phone 2: _____________________________
Unit Brand Name and Type: ____________________________________________________ e.g. Sanyo DVD Player
Serial#: ______________________________ Model#: ______________________________
Problem (please be as specific as possible): _________________________________________
___________________________________________________________________________
___________________________________________________________________________
Do you want AccuServ’s Same Day Service? Yes No
I have read and agree to the terms specified in the Terms of Service document. Initials: _______
Method of Payment: Check or Money Order Credit/Debit Card
If paying by credit card, sign here stating that you agree to the terms of your card and agree to pay the amount of: $______________ to card number xxxxxxx __ __ __ __ (last 4 digits only)
X _________________________________________________________________________
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AccuServ®,
A Division of TeleRepair, Inc. |
