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: __________________

 

Service/Product requested:

_______ Repair/Restoration of Original AM Radio

______ AM/FM Stereo Conversion

Other request or special instructions: _______________________________________

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For Office Use Only:

Date Received: __________________________ Condition: __________________________________________

Knobs: __________ Speaker: __________ Brackets: __________ Other: ____________________________

Unit Model Number: ____________________________________ Reference: ____________________________

 Notes: _____________________________________________________________________________________

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