MONITOR REPAIR FORM 		--==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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