MINILEC SERVICE LLC

  9207 Deering Avenue, Suite A
Chatsworth, CA 91311
 
Customer Information
Account # (if known) __________________
Company Name ____________________
Contact ___________________________
Address (no PO boxes)________________
City ______________________________
State __________ Zip _______________
Day Phone #__________________________
Fax # ____________________________
 
Unit Information
Serial Number ______________________
Capcode (if known)____________________
Frequency _________________________
Service Provider ____________________
Password (if known) ___________________
 
 
     
 
Failure: (Select all that apply)    
o A:AUDIO o F:DISPLAY o M:LIGHT o U:NO COMPLAINT
o B:DEAD o G:CHECK OPERATION o N:RESET o W:REPROGRAM TO:
o B1:DISABLED o H:INTERMITTENT o O:NO PAGE ___________________
o C:FREQ CHANGE o I:SWITCH o P:VIBRATOR (New capcode/baud rate)
(New freq: )__________ o J:VOLUME CONTROL o Q:FALSING o X:SQUELCH
o D:BATTERY o K:DAMAGED o R:LENS o Z:STORED VOICE
o E:POOR RANGE o L:HOUSING o S:LABEL o Other (specify below)
Comments/Requests ________________________________________________________
_________________________________________________________________________
 
Billing Information
Pager will be returned unrepaired if you do not send payment
or proof of purchase document.
Payment Enclosed:
  o Cashiers Check o Money Order o Company Check o Credit Card (Visa, M/C)
Credit Card # __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ Exp.Date:____/____Mo/Yr
(Credit card numbers are Confidential Proprietary Information)
 
Print Name of Card Holder ___________________________________________________
 
Signature of Card Holder ____________________________________ Date ___________
If the pager was purchased within the last year, please attach a proof of purchase (Bill of Sale or Receipt showing the date of purchase and either the Serial Number or Capcode of the pager)
  Rev. 04/19/02
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