Please complete and print clearly. All information MUST BE provided before unit will be serviced.

Name: ____________________________________________________

Address: __________________________________________________

City: ___________________________ State: ______ Zip: __________

EMAIL ADDRESS: _________________________________________

Home Phone: (____) __________ - ___________ ....Cell Phone: (____) ___________ - ___________

UNIT DETAILS: Make: ______________ Model: ______________ Serial#: _________________

PROBLEM / SYMPTOMS Or SERVICE(S) REQUESTED: (explain in detail to the best of your ability)
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

SHIPPING / PACKAGING GUIDELINES:
* You are responsible for the packaging when shipping to us.
* You can insure your unit for just a few dollars, but the best insurance is to package it correctly.
* DM CB Radio Products currently ships via USPS only.

NOTE: Required Return Shipping Fee is based on current USPS Flat Rate Large Box pricing.

Please Check One: [___] ESTIMATE FIRST ( $15.00 ) or [___] OK TO REPAIR UP TO $ ____ . 00

NOTE:
* DM CB Radio Products will contact you before any work is performed on your unit, so, BE SURE to supply contact information clearly and correctly.
* No work will be performed if your signature is not provided below in this agreement.

Signature: __________________________________________ Date: ___ / ___ / 20__

Print Name: ______________________________________

Enclosed is my Check / Postal Money Order for $_____ . 00 (check must clear before work begins)
Pay Pal Payments must be made to: Dodgem250@somd.net

Please print this form, fill it out completely, and enclose with unit for service / repair and be sure to make your Check or Postal Money Order payable to:

Dwight A. Owens Jr.
39 Elder Place
Indian Head, Maryland 20640