Ship To: Chad Entringer, 1233 Emilie St, Green Bay, WI 54301

Contact info:

Phone#:(                )________________________________________

Email: __________________________________________________


Return shipping info:

Name:________________________________________________________________________________________________

Company (if avail):_______________________________________Web____________________________________________

Address:______________________________________________________________________________________________

City:_____________________________________________ State:___________ Zip:_________________________________

Return shipping to a residential or commercial address? PLEASE CIRCLE ONE.

Todays Date:____/_____/_____

* Monitor board model / brand: _________________________________________________________________

QTY:_______ Symptom(s):____________________________________________________________________


* Monitor board model / brand: _________________________________________________________________

QTY:_______ Symptom(s):____________________________________________________________________


* Monitor board model / brand: _________________________________________________________________

QTY:_______ Symptom(s):____________________________________________________________________


* Monitor board model / brand: _________________________________________________________________

QTY:_______ Symptom(s):____________________________________________________________________


Payment Method: X that apply

[ ]I have included a personal check or money order made out to Chad Entringer along with the repair.
[ ]I already prepaid with PayPal.
[ ]I will be paying with a credit card.
Please charge to card after my board(s) are ready to ship back repaird.
[ ]Visa [ ]MasterCard [ ]Discover [ ]American Express

Card number___________________________________________________________________________________

Expiration Date_________________________(MM/YYYY)

[ ]Please send an email, call or PayPal invoice to me when my board(s) is ready to ship back repaired

[ ]Send a paypal invoice to: Email: ___________________________________________________________________
[ ]Give me a call, I will either PayPal, provide credit card, or send a personal check or money
order through the mail.
[ ]Email me, I will either PayPal, provide credit card, or send a personal check or money order
through the mail.


Special Instructions / Comments:_____________________________________________________________________________

______________________________________________________________________________________________________

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