PLEASE! PRINT OUT AND SEND WITH EQUIPMENT  Home    Your Name: Date: Your Shipping Address: ______________________________ ______________________________ ______________________________ ______________________________ Home Ph:_____________________ Contact Ph:_____________________ Work:_________________________ Cell Ph :______________________ E-mail: _______________________ Year of Car: Make of Car:          Model: Item Model # Item Serial # In Warranty? Yes ___No___Date___/___ /___   Description of Problems:               ___________________________________________________________________________________ Name on Card, First__________________ Last _____________________   Visa or M/C# ______________________________Date Exp___________   Please Print this page, Cut along the dashed line below for mailing label -----------------------------------------------------------Ship To----------------------------------------------------------   CorvetteRadios.Com 1755 E. Maple Road Eunice, LA 70535-6432   ------------------------------------------------------------Cut--Here---------------------------------------------------------