Customer Repair Form

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Instructions:

1. Print out a copy of this form, then please fill it out completely legible.

2. Enclose this form with any other comments that you have in an envelope along with your $50 (US Dollars) deposit check made out to:  KMST Television, Inc.

3. Please pack your equipment properly.  We recommend enclosing the radio in a plastic bag and then double boxing in good quality boxes.  Use the smallest boxes you can to do the job.  Shipping is more for larger boxes. Wadded up newspaper is NOT a good cushion or packing material to use.  Bubble wrap is preferred, or to a lesser extent Styrofoam peanuts. Label Fragile.

4. Send completed Form, Check and equipment to:

Ken Seymour
9115 SW 176th Avenue
Beaverton, OR 97007
503-642-9115

Name:_______________________________________________________

Address:_____________________________________________________

Address: ____________________________________________________

City: __________________________ State:_________ Zip:____________

Telephone/s:__________________________________________________

Email address: _______________________________________________

Describe Problem _____________________________________________

___________________________________________________________

Equipment Manufacturer: _______________________________________

Equipment Model Number: ______________________________________

If a car radio, what is make and year? ______________________________

Check if the car is positive or negative ground?   _______ Neg  _______ Pos